Other·May 2, 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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 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 2/8/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about abuse and quality of care. The facility failed to protect the residents’ rights to be free from neglect and physical abuse[GN1] inflicted by another resident for Resident 1[UT2], who was confused, at high fall risk, and had wandering behavior (moving around without any clear purpose or direction). The facility failed to: 1. Ensure Resident 1 was provided with supervision, redirection, and monitoring of her whereabouts. 2. Implement its policies and procedures (P&P) on Wandering and Elopement, Managing Fall, Fall Risk, Fall Reduction, Accident/Incident Prevention, and Safety and Supervision of Residents, and Abuse, Neglect, Exploitation and Misappropriation Prevention and Investigations. 3. Ensure Residents 1 was provided with monitoring and supervision to keep her free from physical abuse from Resident 2. As a result, on 2/1/2024, at 5:10 pm, when Resident 1 attempted to enter Resident 2’s room, Resident 2 pushed Resident 1 out of his room causing Resident 1 to fall backwards onto the hallway floor and hit the back of her head which required immediate transfer to a General Acute Care Hospital [UT3](GACH ), where Resident 1 was diagnosed with blunt head trauma (sudden impact involving the head) and acute on chronic subdural hematoma (a collection of blood between the covering of the brain and the surface of the brain). Moreover, based on the Reasonable Person Concept[GN4], due to Residents 1’s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering), skills and medical condition, an individual subjected to abuse and neglect may have psychological effects including feelings of hopelessness, helplessness, and humiliation[GN5]. A review of Resident 1’s Admission Record indicated the facility admitted the 53-year-old female resident on 9/14/2023 with diagnoses including unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and adult failure to thrive[UT6]. A review of Resident 1’s History and Physical (H&P) exam, dated 9/16/2023, indicated Resident 1 was unable to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 12/27/2023, indicated Resident 1 had impaired cognition. The functional limitation in range of motion (movement of a joint) section of the MDS indicated Resident 1 had no impairment on upper and lower extremities and was able to walk and transfer without assistance. The MDS also indicated Resident 1 did not have wandering behavior. A review of Resident 1’s Change of Condition (COC)/Interact Assessment Form, dated 2/1/2024, completed by Registered Nurse 1 (RN 1) indicated hearing a loud thud coming from the Station B hallway. RN 1 documented assessing Resident 1 lying on the ground in a supine (on the back) position, was tensed, had a significant bump on the right side of the head, and that the left pupil appeared dilated (when the black center of the eyes is larger than normal) and cloudy. RN 1 was unable to assess Resident 1’s eye reactivity to light. The COC indicated Resident 1 required immediate transfer to GACH by paramedics. A review of Resident 1’s GACH H&P exam with a date of service 2/2/2024, indicated Resident 1 was admitted on 2/1/2024. The H&P indicated Resident 1 had diagnoses of blunt head trauma, acute on chronic subdural hematoma, and dementia. A review of Resident 1’s (Re)Admission Assessment, dated 2/7/2024, indicated the resident returned to the facility on 2/7/2024 (six days after Resident 1’s transfer to GACH 1) with diagnoses of fall with blunt head trauma and acute on chronic subdural hematoma. The skin condition section of the Admission Assessment indicated Resident 1 had a lump to the right side of head. A review of Resident 2’s Admission Record indicated the facility admitted the 70-year-old male resident on 9/24/2021, and readmitted Resident 2 on 7/7/2023. Resident 2’s diagnoses included schizophrenia (mental disorder in which people interpret reality abnormally), mood disorder (mental health condition marked by disruptions in emotions), unspecified dementia, and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy). A review of Resident 2’s H&P exam, dated 6/30/2023, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2’s Care Plan titled, “Altered behavior patterns related to dementia, anxiety, and schizophrenia manifested by aggressive behavior, constantly goes to the nursing station and takes all the juice, food, and cups,” [UT7]dated 9/4/2023, had goals to reduce the behavior daily with interventions including assessing what may cause and trigger Resident 2’s behavior, and to attempt to eliminate those triggers, if possible. A review of Resident 2’s MDS, dated 1/4/2024, indicated Resident 2 had impaired cognition. Resident 2 was able to walk and transfer without the use of a wheelchair or other mobility device. A review of Resident 2’s COC/Interact Assessment Form, dated 2/2/2024, indicated Resident 2 verbalized that he (Resident 2[UT8]) pushed another resident. On 2/8/2024, at 2:29 p.m., Resident 1 was observed lying in bed. Resident 1’s Family Member 1 (FM 1) was at bedside. FM 1 stated that prior to the hospitalization on 2/1/2024, Resident 1 was able to walk around. FM 1 stated Resident 1 liked to walk. FM 1 stated he did not know how Resident 1 fell because the facility staff (not identified) just told him that Resident 1 needed to be transferred to the hospital. During an interview on 2/8/2024, at 3:40 p.m., the Director of Nursing (DON) stated Resident 1’s injury (on 2/1/2024 at 5:10 p.m.) was reported to CDPH local District Office as an unusual occurrence because of the avoidable unwitnessed fall with injury and was not reported as an incident of resident-to-resident abuse because their investigation determined it was not abuse. During an interview on 2/9/2024, at 7:45 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was an active walker, walked on her own, went to the other end of the hallway, and throughout the facility. CNA 1 stated Resident 1 had behaviors of going in and out of other residents’ room and did not know where her (Resident 1) own room was. CNA 1 stated that some residents do not mind if another resident who is not from their room enter while other residents would tell them to get out of their room. On 2/9/2024, at 12:55 p.m., the video surveillance recording of the incident between Residents 1 and 2 (on 2/1/2024 at 5:10 p.m.) was observed in the presence of the Administrator (ADM). Resident 1 was observed walking aimlessly in the hallway, staff were passing meal trays, and Resident 1 went inside two different residents’ rooms prior to entering Resident 2’s room. Once Resident 1 enters Resident 2’s room, the video immediately showed Resident 1 falling backwards forcefully on the hallway floor. Subsequently, Resident 2 was observed stepping out of the room and remained standing by the door. The video did not capture Resident 2 pushing Resident 1. The ADM stated Resident 1’s fall was unwitnessed and although Resident 2 reported pushing Resident 1, the facility did not consider the incident as abuse because Resident 2 was not a reliable historian. The ADM stated Resident 1 could have tripped and fell backwards. The ADM stated the Hallway Monitor Staff 1 (HMS 1) was assigned to monitor residents at Station B hallway but had left the area at the time of the fall. The ADM acknowledged there was no P&P regarding HMS[UT9]. During an interview on 2/9/2024, at 2:25 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 2 was always in his room and rarely went out of his room. LVN 1 stated Resident 2 would ask for juice because of his diabetes. LVN 1 stated Resident 2 kept his distance from staff and residents so that no one bothered him (Resident 2). LVN 1 stated Resident 2 did not interact with other residents or with his roommates. LVN 1 stated Resident 2 would usually get out from his room or push his call light when other residents entered his room to ask staff to get the other residents out of his room. LVN 1 stated Resident 2 took antipsychotic medication for mood swings. LVN 1 stated Resident 2 would take juice and food from other residents and would become defensive whenever staff tried to take them away from him. During an interview on 2/12/2024, at 12:05 p.m., HMS 1 stated he was working on 2/1/2024, when Resident 1 had a fall, but he did not witness it. HMS 1 stated he was assigned to Station B hallway and around 5 p.m. he escorted some visitors to the downstairs dining area using the elevator. HMS 1 stated that the fall happened during the transition when the morning activity staff left, and HMS 2 was supposed to come up to relieve the morning shift, but HMS 2 came after 5 p.m. HMS 1 stated he was left alone for a little while. HMS 1 further stated that the facility did not have a specific time for HMS to make rounds or coverage and that the HMS just keep an eye on residents and intervene based on what they can do. HMS 1 stated all staff are responsible for the residents’ safety. A review of the current facility-provided P&P titled, “Abuse and Mistreatment of Residents,” approved by the facility’s Resident Care Policy Committee in 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. Abuse was defined 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 facility’s P&P titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” with a review dated 7/2023, indicated, “1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including but not necessarily limited to: a. Facility staff e. Staff from other agencies j. Any other individual 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.” A review of facility’s P&P titled, “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating,” dated 3/2023 indicated, “Investigating Allegations: 1. All allegations are thoroughly investigated. The Administrator initiates the investigations. 13. The following guidelines are used when conducting interviews: y. Witness statements are obtained in writing, signed, and dated. The witness may write his/her statement, or the investigator may obtain a statement.” A review of facility’s P&P titled, “Wandering and Elopement,” dated 2/2023, indicated, “If identified as at risk for wandering, elopement or other safety issues, the resident’s care plan will include strategies and interventions to maintain the resident’s safety. A review of facility’s P&P titled, “Safety and Supervision of Residents,” with a review date of 7/2023 indicated, “The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive devices. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident assessed needs and identified hazards in the environment. The type and frequent of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident’s condition.” The facility failed to protect the residents’ rights to be free from neglect and physical abuse inflicted by another resident for Resident 1, who was confused, at high fall risk, and had wandering behavior. The facility failed to: 1. Ensure Resident 1 was provided with supervision, redirection, and monitoring of her whereabouts. 2. Implement its P&P on Wandering and Elopement (a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety), Managing Fall, Fall Risk, Fall Reduction, Accident/Incident Prevention, and Safety and Supervision of Residents, and Abuse, Neglect, Exploitation and Misappropriation Prevention and Investigations. 3. Ensure Residents 1 was provided with monitoring and supervision to keep her free from physical abuse from Resident 2. As a result, on 2/1/2024, at 5:10 pm, when Resident 1 attempted to enter Resident 2’s room, Resident 2 pushed Resident 1 out of his room causing Resident 1 to fall backwards onto the hallway floor and hit the back of her head which required immediate transfer to a GACH, where Resident 1 was diagnosed with blunt head trauma and acute on chronic subdural hematoma. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. [GN1]I recommend omitting these definitions. Abuse and Neglect are not medical terms, and they are widely used in everyday conversation. [UT2]Confirming that this is Resident 1 and NOT Resident 8. Thanks! [UT3]Confirming that Resident 1 was only admitted/seen by one GACH. If so, no need for the "1." Thanks! [GN4]In general I recommend limiting the number of definitions we put in parentheses, as it can really interrupt the flow of the writing. "Reasonable Person Concept" has a specific definition, but it is made up of words that regular people understand and should be able to figure out. [GN5]Same comment. Everyone knows what hopelessness, helplessness, and humiliation are. [UT6]Looks like Nate struck this out. I was going to comment that if you would like to keep this in to please flesh out this acronym for the general public (like me). Thanks! [UT7]Just checking that this is indeed the title of this Care Plan. I've just never seen one this long and detailed. [UT8]I agree with Nate's comment below. I also think that the "he" here refers to Resident 2 and not Resident 1. But please let me know if I'm mistaken. Thanks! [UT9]HMS = Hallway Monitoring Staff? Or is it that the ADM acknowledged that there was not P&P on hallway monitoring?