Health inspection·May 30, 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 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. 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. On 4/15/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual Recertification Survey and investigate a Facility-Reported Incident (FRI) regarding resident abuse. The facility failed to protect Resident 100’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) when on 4/7/2024, Resident 106 pulled the hair of Resident 100 causing Resident 100 to fall on the floor. As a result, Resident 100 was subjected to physical abuse by Resident 106 while under the care of the facility. Resident 100 sustained bleeding to the scalp and pain to the left ankle. 1. A review of Resident 100's Admission Record indicated Resident 100 was admitted to the facility on 3/4/2023 with diagnoses that included a history of falling, difficulty in walking and hypertension (high blood pressure). A review of Resident 100's "History and Physical (H&P- a term used to describe a physician's examination of a resident)" dated 3/9/2023, indicated that Resident 100 had the capacity to understand and make decisions. A review of Resident 100's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 3/1/2024, indicated that Resident 100's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of Resident 100's Change in Condition (COC - when there is a sudden change in a resident's health) Form dated 4/7/2024 at 7:55 a.m., indicated Resident 106 pulled Resident 100's hair causing Resident 100 to sustain a fall. A review of Resident 100's Fall Committee Interdisciplinary Care Team (a group of health care professionals with various expertise who work together toward the goals of their residents) Note, dated 4/10/2024 at 9:59 p.m., indicated that on 4/7/2024 at around 7:55 a.m. Resident 106 went towards Resident 100, grabbed, and pulled Resident 100 by the hair causing Resident 100 to fall on the floor. The note further indicated that Resident 100 was noted with slight bleeding on the scalp caused by Resident 106's fingernails. The note indicated that Resident 100 complained of left ankle pain. 2. A review of Resident 106's Admission Record indicated Resident 106 was admitted to the facility on 12/25/2023 with diagnoses that included hyperlipidemia (having too many lipids [fats] in the blood) and dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). A review of Resident 106's MDS dated 3/27/2024, indicated that Resident 106 had severely impaired cognition. A review of Resident 106's COC Form dated 4/7/2024 at 7:55 a.m., indicated that Resident 106 pulled Resident 100’s hair causing Resident 100 to fall. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/15/2024 at 3:45 p.m., LVN 2 stated that on the morning of 4/7/2024, Resident 106 pulled Resident 100 out of Resident 100's wheelchair. LVN 2 stated "The interaction between the two residents was physical abuse, assault (physical attack). There was physical abuse and physical contact to the extent that the other one was harmed." During an interview with Registered Nurse 2 (RN 2) on 4/16/2024 at 8:48 a.m., RN 2 stated that on 4/7/2024, when Resident 106 pulled Resident 100's hair, Resident 106 "was inflicting physical harm which was abuse, the aggressor (referring to Resident 106) physically abused the victim (referring to Resident 100)." During an interview with Resident 100 on 4/16/2024 at 9:45 a.m., Resident 100 stated that on 4/7/2024, Resident 106 pulled her hair and pulled her out of her wheelchair onto the floor causing injuries to the left side of her head and left foot. Resident 100 stated she was "shaken" by the incident and that "it was scary," causing Resident 100 to feel nervous about the incident. During an interview with the Director of Nursing (DON) on 4/18/2024 at 4:34 p.m., the DON stated that the incident between Resident 106 and Resident 100 that occurred on 4/7/2024 at 7:55 a.m. could have possibly been prevented if facility staff had taken Resident 106 back to the resident's room. During an interview with the Administrator (ADM) and the DON on 4/19/2024 at 1:05 p.m., the ADM and the DON stated that Resident 106 pulling the hair of Resident 100 was deliberate. A review of the facility's policy and procedure titled "Abuse: Prevention and Prohibition Against," last reviewed on 10/2022, indicated that each resident has the right to be free from abuse. The policy defines abuse as a willful (intentional) infliction of injury with resulting physical harm, pain, or mental anguish (suffering). The policy further indicated that willful means that the resident must have acted deliberately. The facility failed to protect Resident 100’s right to be free from physical abuse when on 4/7/2024, Resident 106 pulled the hair of Resident 100 causing Resident 100 to fall on the floor. As a result, Resident 100 was subjected to physical abuse by Resident 106 while under the care of the facility. Resident 100 sustained bleeding to the scalp and pain to the left ankle. The above violation had a direct relationship to the health, safety, or security of Resident 100.