Other·March 7, 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. On 2/5/2024, 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 ensure Resident 1 was free from physical abuse inflicted by Resident 2 as per facility’s policy and procedure (P&P). On 1/21/2024, Certified Nurse Assistant 1 (CNA 1) witnessed Resident 2 punching Resident 1 on the right side of the face. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. 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 re-admitted Resident 1 on 1/12/2024 with diagnoses including heart failure and psychotic disorder (mental disorder that cause abnormal thinking and perceptions). A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-planning tool), dated 12/8/2023, indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated Resident 1 had moderately impaired cognition and required moderate assistance from staff with mobility. A review of Resident 1’s Situation, Background, Assessment, Recommendation (SBAR- a tool used by the health care team to communicate with one another regarding a resident's medical condition) Communication Form dated 1/21/2024, timed at 8 a.m., indicated that at around 7 a.m., Resident 1 was yelling and screaming about his cigarettes at the Nursing Station near Resident 2’s room. The form further indicated that Resident 2 then came out of his room and punched Resident 1’s right side of the face. A review of Resident 1’s Care Plan developed on 1/21/2024, for Resident 1’s risk for emotional distress due to being attacked by Resident 2, indicated, the goal was for Resident 1 not to have any episodes of emotional distress. A review of Resident 1’s Progress Note, dated 1/22/2024, timed at 3:29 p.m., indicated that on 1/21/2024, Resident 2 abruptly came out of his room and physically hit Resident 1’s right temple area (side of the head). The progress notes further indicated that Resident 1 was noted minor abrasions on the right temple. A review of Resident 2’s Admission Record indicated the facility re-admitted Resident 2 on 1/6/2024 with diagnoses including congestive heart failure (the heart does not pump enough blood for the body needs), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities). A review of Resident 2’s MDS, dated 1/12/2024, indicated Resident 2 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 2 had no memory problems and required supervision and assistance from staff with mobility. On 2/5/2024 at 11 a.m., during an interview, Resident 2 stated that on 1/21/2024, he hit Resident 1 because Resident 1 disturbed his sleep. Resident 2 stated that he did not understand why facility staff allowed Resident 1 to yell in the middle of night or in the early morning. Resident 2 further stated that he was so upset that on 1/21/2024, after Resident 1 was yelling and screaming in the hallway, Resident 2 went out into the hallway and hit Resident 1. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/5/2024 at 12:49 p.m., LVN 1 stated that on 1/21/2024, Resident 2 should not have hit Resident 1. LVN 1 stated that unfortunately the incident was resident-to-resident physical abuse. On 2/6/2024 at 12:05 p.m., during an interview, the Director of Nursing (DON) stated that unfortunately the staff were not able to stop the resident-to-resident physical abuse that happened when Resident 2 hit Resident 1 on 1/21/2024. The DON stated that physical abuse should not happen in the facility. A review of the facility’s P&P titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program” revised April 2021 and last reviewed on 8/18/2023, indicated, “Protect residents from abuse …by anyone including, but not necessarily limited to facility staff, other residents…. Any other individual.” The facility failed to ensure Resident 1 was free from physical abuse inflicted by Resident 2 as per facility’s P&P. On 1/21/2024, CNA 1 witnessed Resident 2 punching Resident 1 on the right side of the face. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. 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.