Other·March 5, 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. 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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 1/10/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) about resident abuse. The facility failed to protect Resident 1’s right to be free from physical abuse inflicted by Resident 2 and failed to implement its Abuse Prohibition Policy and procedure (P&P) not reporting to CDPH on 12/25/2023, when Resident 3 witnessed Resident 2 shoving and hitting Resident 1’s head and shoulder area. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility and there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents. Based on the reasonable person concept due to Resident 1’s moderately impaired cognition (ability of think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological effects including feelings of embarrassment and humiliation. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1 on 12/12/2023 with diagnoses that included right knee transient synovitis (inflammation of the joint), and dementia. A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/15/2023 indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1 had moderately impaired cognition and required maximum assistance from staff with mobility. A review of Resident 1’s Change in Condition (COC) Evaluation Form, dated 12/25/2023, timed at 3:24 p.m., indicated that Resident 2 shoved Resident 1 in the head. A review of Resident 1’s Nursing Progress Note, dated 12/26/2023, timed at 9:00 a.m., indicated that on 12/25/2023, Registered Nurse 1 (RN 1) was informed by Licensed Vocational Nurse 1 (LVN 1) of Resident 1 being shoved on the head by Resident 2. A review of Resident 1’s Care Plan, dated 12/25/2023, indicated Resident 1 was at risk for emotional distress due to Resident 1’s head being shoved by Resident 2. The goal was for Resident 1 to not have any episodes of emotional distress. A review of Resident 1’s Psychiatric Evaluation Note dated 12/28/2023, indicated Resident 2 hit Resident on the head. A review of Resident 2’s Admission Record indicated the facility originally admitted Resident 2 on 3/17/2023 and re-admitted the resident on 11/22/2023 with diagnoses that included generalized anxiety disorder (a mental condition characterized by persistent and excessive worry or fear that interferes with daily activities) and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). A review of Resident 2’s MDS dated 11/25/2023 indicated Resident 2 was able to be understood and understand others. The MDS indicated Resident 2 had moderately impaired cognition and required maximum assistance from staff with mobility. A review of Resident 3’s Admission Record indicated the facility admitted Resident 3 on 12/12/2023 with diagnoses that included dysarthria (difficulty speaking because the muscles you use for speech are weak) following cerebral infarction (also called as stroke, occurs when the blood supply to the part of the brain is blocked or reduced). A review of Resident 3’s MDS dated 11/25/2023 indicated Resident 3 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 3 had moderately impaired cognition and required maximum assistance from staff with mobility. A review of Resident 2’s COC Evaluation Form dated 12/25/2023, timed at 2:54 p.m., indicated that Resident 2 “slammed” Resident 1’s head. The COC further indicated that Resident 2’s physician ordered for Resident 2 to be transferred to General Acute Care Hospital 1 (GACH 1) for slamming Resident 1’s head. A review of Resident 2’s Physician Order, dated 12/25/2023, indicated to transfer Resident 2 to GACH 1 for further evaluation due to sudden episodes of irritability, getting upset, and unable to control his temper. A review of Resident 2’s Nursing Progress Note dated 12/27/2023, timed at 11:46 a.m., indicated that on 12/25/2023 at around 1:30 p.m. Resident 2 had an episode of physical aggression towards Resident 1 by shoving the head of Resident 1. The Nursing Progress Note indicated that RN 1 was called to the room by LVN 1. RN 1 intervened by separating Resident 1 and Resident 2. The Nursing Progress Note indicated according to RN 1, Resident 2 was yelling and was very upset accusing Resident 1 of invading Resident 2’s space. During an interview with Resident 1 on 1/10/2024 at 12:48p.m., Resident 1 stated that he was unable to recall the incident on 12/25/2023 where Resident 2 had hit him multiple times. During an interview with Resident 3 on 1/10/2024 at 12:48 p.m., Resident 3 stated that on the day of the incident (12/25/2023), Resident 3 was being visited by Family Member 1 (FM 1). Resident 3 stated that he and FM 1 witnessed Resident 2 hit Resident 1. Resident 3 stated that Resident 2 hit the back of Resident 1’s head and chest area. Resident 3 stated that Resident 2 hit Resident 1 “about four times” and the force used was “pretty hard”. Resident 3 stated that FM 1 told Resident 2 to stop hitting Resident 1. On 1/10/2024 at 1:16 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that on 12/25/2023, FM 1 approached CNA 1 and stated that Resident 2 shoved Resident 1. On 1/10/2024 at 2:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that on 12/25/2023, CNA 1 reported to LVN 1 that Resident 2 (roommate) shoved Resident 1. LVN 1 stated that she immediately entered the residents’ room and observed Resident 2 walking near his own bed. When LVN 1 asked Resident 2 what had happened, Resident 2 did not respond to LVN 1’s question. LVN 1 stated that when she asked Resident 1 what had happened, Resident 1 stated that Resident 2 shoved his head and hit him. During an interview on 1/10/2024 at 3:31 p.m., the Director of Nursing (DON) stated that on 12/25/2023, Resident 2 physically abused Resident 1. The DON also stated that all allegations involving abuse should be reported to CDPH within two (2) hours. The DON stated that the abuse incident between Resident 1 and Resident 2 (occurred on 12/25/2023) should have been reported to CDPH within two hours. The DON stated the facility staff have previously been trained on timely reporting of abuse allegations. On 1/11/2024 at 9:00 a.m., during an interview, FM 1 stated that on 12/25/2023, she witnessed Resident 2 hitting hard (with force) Resident 1 on the back of head twice and on the left shoulder area twice. FM 1 stated after telling Resident 2 to stop hitting Resident 1, FM 1 went outside to the Nursing Station and informed CNA 1. FM 1 stated that she did not understand why Resident 2 hit Resident 1 because Resident 1 did not do anything wrong. A review of the facility’s P&P titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” revised on 8/2023, indicated “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation…. Protect residents from abuse, neglect, exploitation, or misappropriation of a property by anyone including, but not necessarily limited to facility staff; other residents; … any other individual.” The P&P also indicated “Investigate and report any allegation within timeframe required.” The facility failed to protect Resident 1’s right to be free from physical abuse inflicted by Resident 2 and failed to implement its Abuse Prohibition Policy by not reporting to CDPH on 12/25/2023, when Resident 3 witnessed Resident 2 shoving and hitting Resident 1’s head and shoulder area. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility and there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents. Based on the reasonable person concept due to Resident 1’s moderately impaired cognition, an individual subjected to physical abuse has lifetime physical pain and psychological effects including feelings of embarrassment and humiliation. The above violations had a direct relationship to the health, safety, or security of Resident 1.