Health inspection·January 26, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 12/12/2023 the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about quality of care. The facility failed to ensure Resident 1 had the right to be free from physical abuse and neglect from Certified Nursing Assistant 3 (CNA 3) and failed to implement its policies and procedures (P&P) on abuse, safety, and resident rights. On 11/20/2023 at 5:21 p.m., CNA 3 struggled with Resident 1 to remove forcefully a wheelchair Resident 1 was holding, then when Resident 1 held CNA 3’s right hand she swung her right arm causing Resident 1 to fall backwards on the floor. CNA 3 left Resident 1 on the floor, did not check on her, did not call for help, and went on to continue assisting a resident with dinner at another table. As a result, CNA 3 physically abused and neglected Resident 1. In addition, based on the Reasonable Person Concept (refers to a tool to assist the survey team’s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident’s position), due to Resident 1’s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to abuse and neglect may have psychological effects including feelings of hopelessness, helplessness, and humiliation. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, an 84-year-old female, on 8/18/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety disorder, and osteoarthritis (a degenerative [irreversible deterioration] joint disease in which the tissues in the joint break down over time causing pain and stiffness of the joints). A review of Resident 1’s Interdisciplinary Team (IDT- various healthcare disciplines participating in the resident’s care) Behavior Management / Psychotropic (medications that affects behavior, mood, thoughts, or perception) Regimen Review Update, dated 8/19/2023, indicated Resident 1 was taking Seroquel (a psychotropic medication used to treat mental and mood conditions). The Seroquel dose was 50 milligrams (mg – unit of measurement) for inability to process internal stimuli causing anger outburst or stress affecting daily living activities. Resident 1 was also taking Zoloft (a psychotropic medication used to manage depression) 25 mg for inability to cope with daily living activities causing sadness and verbalizing not feeling safe. The non-pharmacological (treatments without the use of medications) interventions indicated providing Resident 1 with a quiet and calm environment, verbal cues, prompting, redirection, diversion, and reassurance. A review of Resident 1’s Care Plan, developed on 8/19/2023 for Resident 1’s fall risk, indicated interventions including frequent visual monitoring and to respect Resident 1’s wishes for independence and dignity. A review of Resident 1’s Care Plan, developed on 8/19/2023 for Resident 1’s anxiety manifested by inability to cope with daily living activities causing anger, indicated interventions including keeping Resident 1 away from stressful situations. A review of Resident 1’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 8/25/2023, indicated the resident had impaired cognition. Resident 1 required limited assistance on transfer, locomotion on and off unit (how resident moves between locations in the resident’s room, adjacent corridor, and off-unit locations on same floor), dressing, and toilet use. The balance during transition and walking section of the MDS indicated that Resident 1 was not steady on walking and turning around. A review of Resident 1’s Change of Condition (COC) / Interact Assessment Form, dated 11/20/2023, indicated Resident 1 had an unwitnessed fall in the dining room. The COC form indicated that Resident 1 was found sitting on the floor in the dining room. Resident 1 did not sustain injuries and the resident was able to stand up and sat on the chair. On 12/7/2023 at 11:26 a.m., during an observation of the surveillance video and concurrent interview with the Administrator (ADM), the following was observed on the day of the incident on 11/20/2023 during the dinner meal: - At 5:18 p.m., Resident 1 walked in the dining room using her four-wheeled walker. Resident 1 went to the second table to sit but there was no chair on Resident 1’s side of the table. Resident 1 looked for a chair to sit and eat dinner, but no staff assisted her. - At 5:21:02 p.m., Resident 1 walked without the four-wheeled walker to the middle of the dining room where there was an empty wheelchair. Resident 1 took the empty wheelchair and pushed it towards the resident’s side of the table. - At 5:21:06 p.m., CNA 3 observed Resident 1 with the wheelchair and went to Resident 1’s right side forcefully trying to remove Resident 1’s grip on the wheelchair handle. Resident 1 did not let the wheelchair loose. - At 5:21:25 p.m., CNA 3 removed Resident 1’s right hand from the wheelchair and Resident 1 grabbed CNA 3’s right hand. While walking away wheeling the wheelchair away, CNA 3 swung her right arm backwards to release Resident 1’s grip on her hand causing Resident 1 to fall on the floor backwards (on her back). - At 5:21:31 p.m., CNA 3 looked down at Resident 1 on the floor and proceeded to walk away with the wheelchair to a table where she (CNA 3) was assisting a resident with eating. - At 5:21:43 p.m., CNA 4 was assisting a resident with the meal tray at a table at the opposite side of the table where CNA 3 was located and saw Resident 1 on the floor. CNA 4 walked to CNA 3 and pointed to Resident 1. Both, CNAs 3 and 4 walked closer to Resident 1, stood beside the resident, and looked down on the resident who was still on the floor and spoke to CNA 4. CNA 3 turned around and walked away from Resident 1 to go back the resident she (CNA 3) was assisting. CNA 4, without checking on Resident 1, went to a wall phone at the dining room to call for assistance. A few seconds later, three licensed nurses arrive to the dining room and check on Resident 1 still lying flat on the floor face up. On 12/11/2023 at 12:53 p.m., during a telephone interview, CNA 3 stated that she was not assigned to Resident 1 and did not know Resident 1’s condition. CNA 3 stated Resident 1 took the wheelchair from the middle of the dining room and refused to give the wheelchair back to her. CNA 3 stated that Resident 1 struggled with her and refusing to allow her (CNA 3) to take the wheelchair away. CNA 3 stated she carefully removed Resident 1’s hand from the wheelchair but the resident attempted to bite and hit her. CNA 3 stated Resident 1 lost her balance and fell on the floor hitting her left side first. CNA 3 stated that she left Resident 1 on the floor because she thought CNA 4 would help the resident. CNA 3, towards the end of the interview, stated that she did not see Resident 1 fall and it was CNA 4 who informed her that Resident 1 was on the floor. CNA 3 was not able to state what could have been done differently to avoid Resident 1’s fall and what could potentially happen to Resident 1. On 12/11/2023 at 1:34 p.m., during a telephone interview, Registered Nurse 2 (RN 2) stated that she saw Resident 1 sitting on the floor and leaning on a chair in the dining room. RN 2 stated Resident 1 did not have any visible injuries. RN 2 stated Resident 1 stood up and walked using the walker. RN 2 stated that CNA 3 informed her that Resident 1 had an unwitnessed fall. RN 2 stated CNA 3 later informed her that Resident 1 struggled with her trying to take the wheelchair which potentially have caused Resident 1’s fall. RN 2 stated CNA 3 should have been gentle and careful with Resident 1 to prevent the fall. RN 2 stated Resident 1 could have potentially sustained injuries from the fall. On 12/11/2023 at 1:56 p.m., CNA 4 was called, did not answer, and did not return the call. On 12/12/2023 at 10:30 a.m., during an interview, the Director of Staff Development (DSD) stated Resident 1 was confused most of the time and takes things that seem to be abandoned. The DSD stated CNA 3 should have redirected Resident 1. The DSD stated that for CNA 3 leaving Resident 1 on the floor after the fall was neglectful. The DSD stated that Resident 1 had the potential for fractures (break in a bone) which could lead to death. The DSD stated that Resident 1 had the potential to be affected emotionally, mentally, and lose trust on the staff. On 12/12/2023 at 11:44 a.m., during an interview, the Director of Nursing (DON) stated that CNA 3 struggled with Resident 1 to take away the wheelchair led to Resident 1’s fall. The DON stated that CNA 3 left Resident 1 on the floor and neglected to call for help. CNA 3 turned away from Resident 1 and proceeded to attend to the other residents in the dining room. The DON stated CNA 3 failed to follow the facility’s procedure on care of fall risk residents. The DON stated Resident 1 had the potential to be affected emotionally and mentally. A review of the current facility provided P&P titled, “Abuse and Mistreatment of Residents,” dated 7/2023, indicated the purpose of the policy was to uphold the resident’s right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The facility defined abuse as the willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm, pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. A review of the current facility provided P&P titled, “Safety and Supervision of Residents,” dated 7/2023, indicated the facility strived to make the environment as free from accident hazards as possible. The policy indicated that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The policy indicated the individualized resident-centered approach to safety included implementing interventions to reduce accident risks and hazards. A review of the current facility provided P&P titled, “Resident Rights – Exercise of Rights,” dated 7/2023, indicated the facility would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes safety and maintenance or enhancement of his or her quality of life, recognizing each resident individuality. The facility failed to ensure Resident 1 had the right to be free from physical abuse and neglect from CNA 3 and failed to implement its P&P on abuse, safety, and resident’s rights. On 11/20/2023 at 5:21 p.m., CNA 3 struggled with Resident 1 to remove forcefully a wheelchair Resident 1 was holding, then when Resident 1 held CNA 3’s right hand she swung her right arm causing Resident 1 to fall backwards on the floor. CNA 3 left Resident 1 on the floor, did not check on her, did not call for help, and went on to continue assisting a resident with dinner at another table. As a result, CNA 3 physically abused and neglected Resident 1. In addition, based on the Reasonable Person Concept, due to Resident 1’s impaired cognition and medical condition, an individual subjected to abuse and neglect may have psychological effects including feelings of hopelessness, helplessness, and humiliation. The above violations, jointly, separately, or in any combination, had a direct relationship to the health, safety, or security of Resident 1.