Other·December 9, 2022

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. 42 CFR § 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72311 Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 10/20/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) regarding quality of care. The facility failed to ensure Resident 1, who had verbalized suicidal ideation (thoughts or ideas of ending one's own life), was kept free from neglect (failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress), and was provided with one-to-one staff supervision (one staff always with the resident, a sitter) as ordered by the psychiatrist (medical doctor who specializes in mental health) and as per plan of care. On 10/18/2022, at around 7:15 p.m., Care Partner 1 (CP 1), the assigned sitter, left Resident 1 unsupervised between five (5) to 10 minutes. As a result, Resident 1 used a knife to stab himself multiple times in the abdomen, both thighs, and left arm before Certified Nursing Assistant 1 (CNA 1) found him. Paramedics (healthcare professionals specialized in emergency treatment) transferred Resident 1 to an emergency room (ER) in a general acute care hospital (GACH). A review of Resident 1's Admission Record indicated the resident, a 59-year-old male, was admitted on 10/7/2022 with diagnoses including major depressive disorder (mood disorder that causes persistent feelings of sadness), malignant neoplasm (cancerous tumor [abnormal growth of body tissue]) of the peritoneum (membrane that lines the inner abdominal wall and covers the organs within the abdomen), and dysphagia (difficulty swallowing). A review of Resident 1's History and Physical exam, dated 10/8/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Care Plan initiated on 10/10/2022 for the resident’s mood problem related to depression manifested by suicidal ideation, included in the interventions that a one-to-one sitter would be provided. A review of Resident 1's Psychiatry Evaluation dated 10/11/2022 indicated the resident verbalized thinking of killing himself. The psychiatrist documented Resident 1 was acutely suicidal and recommended maintaining strict suicide precautions with a one-to-one sitter and transferring Resident 1 to an acute psychiatric hospital, if possible. A review of Resident 1's Progress Notes, noted as a late entry on 10/19/2022 and timed 6:25 p.m., indicated on 10/18/2022 at 7:30 p.m., CNA 1 informed Licensed Vocational Nurse 1 (LVN 1) Resident 1 was bleeding and needed attention. LVN 1 found Resident 1 in his room with a knife in his hand and a laceration (cut) to his right thigh with active bleeding. The knife was confiscated, LVN 1 applied pressure to the actively bleeding right thigh wound, paramedics were called at 7:40 p.m., and took over Resident 1’s care at 7:45 p.m. At 8 p.m., paramedics transferred Resident 1 to an ER in a GACH. A review of Resident 1's Progress Notes, noted as a late entry, dated 10/19/2022 and timed 8:10 p.m. indicated on 10/18/2022 at 7:30 p.m., LVN 1 informed Registered Nurse 1 (RN 1) that Resident 1 was bleeding. RN 1 noted Resident 1 had multiple stabbing wounds on the resident’s left and right thighs and abdomen. Paramedics were called and transferred Resident 1 to an ER in a GACH. A review of Resident 1's Change in Condition Evaluation, dated 10/18/2022, indicated the resident had a large bleeding laceration on the front of the right thigh, multiple lacerations on the front of the left thigh, on the left arm, and on the abdomen. On 10/24/2022 at 2:28 p.m., during an interview, the Administrator (ADM) stated Resident 1 had verbalized suicidal ideations and after being evaluated by the psychiatrist on 10/11/2022, a recommendation was made for Resident 1 to have a one-to-one sitter. According to the ADM, on the evening of 10/18/2022, around 7:20 p.m. to 7:30 p.m., CP 1 left Resident 1's room to assist with another resident who was a high fall risk and was trying to get out of bed. It was during this time when CP 1 was not in the room that Resident 1 secured a knife and started stabbing himself. The ADM could not provide information where and how Resident 1 obtained the knife. The ADM stated Resident 1 was left unsupervised for approximately five (5) to 10 minutes before he was found by CNA 1. The ADM stated there should have been always a staff member in the room with Resident 1. On 10/24/2022 3:46 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 did not have a formal doctor's order for one-to-one supervision, but the psychiatrist's recommendation was treated like a formal doctor's order. On 10/24/2022 at 5:30 p.m., during an interview, CP 1 stated her role as a care partner was to aid where needed. CP 1 stated she had been assigned as Resident 1’s sitter and knew he needed constant monitoring because he wanted to kill himself. CP 1 stated on the evening shift of 10/18/2022, she was instructed to keep an eye on both Resident 1 and Resident 2. CP 1 stated Resident 2 was a high fall risk and was actively trying to get out of bed. CP 1 stated she was sitting in Resident 1's room but placed her chair closer to the hallway so she could keep an eye on both Residents 1 and 2. CP 1 stated at around 7:15 p.m. she could see Resident 2 attempting to get out of bed, so she left Resident 1 and went into Resident 2's room. On 10/25/2022 at 3:18 p.m., during an interview, CNA 1 stated on 10/18/2022 at around 7:30 p.m., he was passing by Resident 1's room and noticed blood on Resident 1's gown. When CNA 1 approached Resident 1, he noticed the resident had a knife in his right hand and his right thigh was heavily bleeding. There was no other staff in the room with Resident 1. CNA 1 stated he immediately called for help and LVN 1 and Registered Nurse 1 (RN 1) came right away. During an interview on 10/25/2022 at 3:35 p.m., RN 1 stated on 10/18/2022 at around 7:30 p.m., she was alerted by LVN 1 that Resident 1 was bleeding. RN 1 stated when she arrived at Resident 1's room, she observed Resident 1 stabbing himself repeatedly in the abdomen with a sharp knife. RN 1 stated that with the help of LVN 1, they were able to confiscate the knife and put pressure on the wounds until the paramedics arrived. RN 1 stated CP 1was not in the room during the incident. RN 1 stated she never instructed CP 1 to watch over both Residents 1 and 2. RN 1 stated CP 1 should not have left Resident 1 and if she needed to leave for any reason, she should have called for another staff to relieve her. A review of the facility's policy and procedures titled, "Neglect Policy," dated 3/2018, indicated the facility will ensure residents receive the necessary staff, supplies, services, policies, training, or staff supervision and oversight to meet their needs. A review of the facility's policy and procedures titled, "Safety Supervision of Residents," dated 7/1/2020, indicated resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The facility failed to ensure Resident 1, who had verbalized suicidal ideation, was kept free from neglect, and was provided with one-to-one staff supervision as ordered by the psychiatrist and as per plan of care. On 10/18/2022, at around 7:15 p.m., CP 1, the assigned sitter, left Resident 1 unsupervised between five (5) to 10 minutes. As a result, Resident 1 used a knife to stab himself multiple times in the abdomen, both thighs, and left arm before CNA 1 found him. Paramedics transferred Resident 1 to an ER in a GACH. 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 Resident 1.