Health inspection·June 21, 2024

42 CFR § 483.10 Resident rights. (a) Residents rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. care and treatment. . . . (e) Respect and dignity. The resident has a right to be treated with respect and dignity, including: 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 § 72311 Nursing Service – General (a) Nursing service shall include, but not be limited to, the following:(1) Planning of patient care, which shall include at least the following:(A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. 22 CCR § 72315 Nursing Service – Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 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. . . . (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 5/3/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident regarding an abuse allegation. As a result of the investigation, CDPH determined that the facility failed to: 1. Prevent physical abuse by CNA 1 when CNA 1 hit (slap and punch) Resident 1 on 5/1/24 in accordance with the facility’s policy & procedure titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated 4/2021. 2. Ensure Resident 1 did not experience abuse in accordance with Resident 1's Abuse Care Plan, dated 9/30/2023. 3. Ensure CNA 1 received abuse training in accordance with the facility’s policy and procedure titled, "Abuse & Mistreatment of Residents.” As a result, on 5/1/2024 at 5:30 p.m., Student Nurse 1 (SN 1) walked in Resident 1's room and witnessed CNA 1 slapping and punching Resident 1 in Resident 1's arms and back. Resident 1 was subjected to physical abuse inflicted by CNA 1 while under the care of the facility. A review of Resident 1's Admission Record, indicated the facility admitted the 74-year old female resident on 6/21/2021 and readmitted the resident on 9/3/2023 with diagnoses including dementia (loss of memory and other mental abilities severe enough to interfere with daily life), mood disorder (a mental health condition that causes severe disruptions in emotions), anxiety disorder (a mental health disorder characterized by feelings of worry), and major depressive disorder (persistent feeling of sadness and loss of interests). A review of Resident 1's History and Physical, dated 9/5/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Abuse Care Plan, dated 9/30/2023, indicated Resident 1 and/or Resident 1's “responsible party have been made aware that the facility had stable systems to prevent not only abuse but also those practices and omissions, neglect and misappropriation of property that is left unchecked, (that can) lead to abuse.” The care plan indicated Resident 1 “shall not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies, family member or legal counsel.” The goal was for Resident 1 to be free from abuse daily until the next assessment (6/17/2024). The approached interventions were for staff to ensure a safe environment and the resident is free from abuse by providing monitoring and providing supervision to Resident 1. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screen tool), dated 3/19/2024, indicated Resident 1 had severe impaired cognition. The MDS indicated Resident 1 required moderate assistance with personal hygiene, lower body dressing, toileting hygiene, and putting on/off footwear. The MDS indicated Resident 1 had symptom presence of feeling down, depressed, or hopeless. A review of Resident 1's Change of Condition (COC, a term used to describe a significant worsening of a patient's/resident's physical health) Report, dated 5/1/2024 at 5:40 p.m., indicated (on 5/1/2024) at 3 p.m. Resident 1 was noted ambulating (walking) down station 1 hallway with no apparent distress or discomfort. The COC report indicated that (on 5/1/2024) at 5:30 p.m., SN 1 reported to SN 1's Clinical Instructor (CI) that SN 1 saw CNA 1 moving CNA 1's arms in the form of "punching" Resident 1. The COC report indicated SN 1 noted CNA 1 in Resident 1's room with CNA 1's back facing the doorway and appeared to be punching Resident 1. The COC report indicated SN 1 could not see where CNA 1 was punching Resident 1, but SN 1 was able to see CNA 1's back and CNA 1's punching movements towards Resident 1. The COC report indicated Resident 1 was screaming for help, was "defending herself (had her arms covering her face)." During a telephone interview with SN 1 on 5/7/2024 at 8:36 a.m., SN 1 stated that on 5/1/2024 at around dinner time (unable to recall the exact time) SN 1 went into Resident 1's room to look for CNA 1. SN 1 stated as she walked into Resident 1's room, she witnessed CNA 1 "slapping and punching" Resident 1 in Resident 1's arms and back. SN 1 stated, Resident 1 was trying to protect her face with her arms up and attempting to hit CNA 1 back. SN 1 stated CNA 1 was slapping Resident 1's arms, then Resident 1 turned around to get away from CNA 1, then CNA 1 proceeded to punch Resident 1's back with a closed fist. SN 1 stated she saw Resident 1 and CNA 1 fall on the floor. SN 1 stated Resident 1 was crying and yelling for help. SN 1 stated, she assisted Resident 1 back to bed. SN 1 stated Resident 1 yelled, "Do not let that monster back in here." SN 1 stated she left the room and notified her CI that she witnessed CNA 1 hitting Resident 1. SN 1 stated the CI, the Assistant Director of Nursing (ADON), Registered Nurse 1 (RN 1) and herself went into an office, and she notified them (the CI, the ADON and RN 1) that she witnessed CNA 1 hitting and punching Resident 1. During a telephone interview with CNA 1 on 5/7/2024 at 8:55 a.m., CNA 1 stated, on 5/1/2024, (unable to recall exact time) Resident 1 went to get a glass of milk from Resident 1 roommate's lunch tray, and CNA 1 went towards Resident 1 to grab the glass of milk back from Resident 1. CNA 1 stated CNA 1 told Resident 1 that was not her (Resident 1's) milk. CNA 1 stated, Resident 1 slapped her (CNA 1), and Resident 1 lost her (Resident 1's) balance, but she (CNA 1) was able to catch her (Resident 1) before she Resident 1 fell. CNA 1 stated, she then saw SN 1 in the room after she caught Resident 1 from falling. CNA 1 stated she assisted Resident 1 back to her bed. During an interview with the Social Worker (SW) on 5/7/2024 at 2:30 p.m., the SW stated, Resident 1 was pleasant and cooperative. The SW stated Resident 1 had short term memory loss. The SW stated that ever since she (the SW) had been working with Resident 1, she had not witnessed Resident 1 being physically aggressive with any staff or other residents. The SW stated if Resident 1 became frustrated she was easily redirectable. The SW stated she went to conduct a psychosocial assessment (an evaluation of a person's mental, physical, and emotional health) on Resident 1 the day after (5/2/2024) she was notified that SN 1 witnessed CNA 1 hitting and punching Resident 1. The SW stated Resident 1 told her (the SW) that she (Resident 1) did not remember the incident (when CNA 1 hit Resident 1). During an interview with the CI on 5/7/2024 at 3 p.m., the CI stated he (the CI) was on the other side of the facility working with other students, and SN 1 reported to him that when she (SN 1) walked into Resident 1's room, she witnessed CNA 1 with a closed fist punching Resident 1. The CI stated they (the CI and SN 1) both went to notify RN 1. The CI stated they went inside the ADON's office with RN 1. The CI stated RN 1 went to assess Resident 1. The CI stated SN 1 was crying about "what she witnessed." During an interview with RN 1 on 5/7/2024 at 4 p.m., RN 1 stated Resident 1 was calm and had mood swings especially on shower days (unspecified dates). RN 1 stated Resident 1 did not like to take showers. However, Resident 1 was redirectable. RN 1 stated she (RN 1) had not seen Resident 1 being aggressive toward any of the staff or other residents. RN 1 stated she was at the nurse's station when the CI came to tell her (RN 1) that he (the CI) needed to report a serious matter. RN 1 stated SN 1, the CI, and the ADON went into an office, and SN 1 said that she witnessed CNA 1 punching Resident 1 inside Resident 1's room. RN 1 stated SN 1 told them (RN 1, the CI and the ADON) that Resident 1 was trying to protect herself (Resident 1). RN 1 stated SN 1 was "visibly upset." RN 1 stated she went to assess Resident 1 and Resident 1 did not have any injuries. During an interview with the ADON on 5/7/2024 at 4:30 p.m., the ADON stated (on 5/1/2024, unable to recall exact time) SN 1 came into her (the ADON's) office with her (SN 1's) instructor and reported physical abuse by CNA 1 toward Resident 1. The ADON stated SN 1 said she walked into Resident 1's room, where CNA 1 was, to report a feeding percentage for another resident (Resident 2) and saw CNA 1 punching Resident 1 with a closed fist. The ADON stated SN 1 said she (SN 1) put Resident 1 back on her bed, and then she went to report to her instructor. During a telephone interview with Resident 1's Family Member 1 (FM 1) on 5/8/2024 at 2 p.m., FM 1 stated the facility called her on 5/1/2024 (unspecified time) and told her (FM 1) that Resident 1 hit the CNA 1. FM 1 stated the facility did not tell her that SN 1 saw CNA 1 hit Resident 1. FM 1 stated Resident 1 has been telling her that someone in the facility has been hitting her (Resident 1). During an interview with the Director of Nursing (DON) and a concurrent review of CNA 1's undated employee file, on 5/9/2024 at 8:30 a.m., the DON stated she was not in the building when SN 1 witnessed CNA 1 hitting and punching Resident 1. The DON stated she was informed by her assistant that SN 1 witnessed CNA 1 punched Resident 1. The DON stated she instructed her (the DON's) assistant to notify the Administrator (ADM). A review of CNA 1's employee file indicated CNA 1's employee file had an unsigned form titled, "Abuse Allegation Reporting," dated 4/15/2019. The DON stated "this form" was the only education on abuse in CNA 1's employee file. The DON stated, the form has CNA 1's name printed, however CNA 1 needed to sign the document to ensure CNA 1 read the information and was agreeable. The DON stated it was the staff developer's responsibility to keep the employee charts up to date, but currently the facility does not have a staff developer working in the facility. A review of the current facility-provided P&P titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated 4/2021, indicated Residents have the right to be free from physical abuse. A review of the facility's undated P&P titled, "Abuse & Mistreatment of Residents," indicated "by way of orientation and continuing education sessions, all facility staff shall receive training on issues related to abuse-prohibition practices such as the CDPH mandated abuse reporting video in the mandated in-service sessions." The P&P indicated "employee attendance at orientation shall be verified by a signed and dated receipt of the copy of resident rights, facility P&P on abuse prevention and mandated reporting. A copy of signed receipt shall be maintained in employee file." The facility failed to: 1. Prevent physical abuse by CNA 1 when CNA 1 hit (slap and punch) Resident 1 on 5/1/24 in accordance with the facility’s policy & procedure titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated 4/2021. 2. Ensure Resident 1 did not experience abuse in accordance with Resident 1's Abuse Care Plan, dated 9/30/2023. 3. Ensure CNA 1 received abuse training in accordance with the facility’s policy and procedure titled, "Abuse & Mistreatment of Residents.” As a result, on 5/1/2024 at 5:30 p.m., Student Nurse 1 (SN 1) walked in Resident 1's room and witnessed CNA 1 slapping and punching Resident 1 in Resident 1's arms and back. Resident 1 was subjected to physical abuse inflicted by CNA 1 while under the care of the facility. The above violations had a direct relationship to the health, safety, or security of Resident 1.