Other·August 19, 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. 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: (9) To be free from mental and physical abuse. On 1/18/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a facility-reported incident (FRI) investigation about resident-to-resident abuse. The facility failed to ensure Resident 1, who had severely impaired cognition (the person is unable to remember, learn, understand the meaning or importance of things and situations, communicate needs, and wants, and make decisions), had the right to be free from sexual abuse (non-consensual sexual contact of any type) from Resident 2. On 1/1/2021, at 6 a.m. staff observed Resident 1's body exposed, and Resident 2, a male, was touching Resident 1's vagina. As a result, Resident 1, who has severely impaired cognition and medical condition was sexually abused by Resident 2. An individual who was subjected to sexual abuse has lifetime physical pain and psychological effects including feelings of hopelessness, helplessness and humiliation. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 1/7/2019, with diagnoses including Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and metabolic encephalopathy (brain damage or loss of brain function that is caused by an illness or condition). A review of Resident 1's History and Physical (H&P) exam completed by the attending physician on 1/10/2020 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-planning tool) dated 10/9/2020 indicated Resident 1 could not communicate needs and wants and required extensive to total assistance with activities of daily living (ADLs, such as transfers, eating, dressing, personal hygiene, and bathing). Resident 1 was incontinent (unable to control) of bowel and bladder functions. A review of Residents 1's Progress Note dated 1/1/2021, timed at 6:25 a.m., indicated Licensed Vocational Nurse 1 (LVN 1) received a report that a staff member (Housekeeper 1) found a male resident touching Resident 1's vaginal area. Resident 1 was lying in bed on her back, with her disposable incontinent brief off and her night gown pulled up. Resident 2 was standing near Resident 1's bed, touching her vaginal area. A review of Resident 1's Safety Event Report completed on 1/6/2021 indicated Resident 1 was the suspected sexual abuse victim that occurred on 1/1/2021. Resident 1 did not have the mental capacity to be interviewed. The alleged perpetrator was another resident (Resident 2). A review of Resident 1's Initial Psychological Evaluation dated 1/1/2021 indicated the reason for the evaluation was suspected abuse and during the evaluation, Resident 1 appeared to be sad with low energy. A review of Resident 2's Admission Record indicated the facility admitted the resident on 10/8/2014 with diagnoses including dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) with behavioral disturbance (agitation including verbal and physical aggression and hoarding) and severe major depressive disorder with psychotic symptoms (characterized by a disconnection from reality such as seeing or hearing things that are not really there). A review of Resident 2's H&P exam completed by the attending physician on 8/21/2020 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2's MDS dated 10/7/2020 indicated the resident had unclear speech, was able to walk in the room and corridor with steady balance and without the use of a mobility device. A review of Residents 2's Progress Note dated 1/1/2021, timed at 6:30 a.m., indicated LVN 2 received a report from staff that Resident 2 was found touching Resident 1's vaginal area. Resident 2 was removed from Resident 1's room. A review of Resident 2's Psychological Progress Report dated 1/1/2021 indicated Resident 2 was found in Resident 1's room, touching her vaginal area. Resident 2 had poor concentration and impaired judgement. The recommendation was to provide Resident 2 with 1 to 1 (1:1 one staff with the resident always) monitoring as needed. On 1/8/2021 at 4:20 p.m., during an interview, Director of Nursing 1 (DON 1) stated during the early morning of 1/1/2021 around 6 a.m., Housekeeper 1 was going past Resident 1's room and saw Resident 2 standing near Resident 1's bed., Resident 2 was fully dressed and touching Resident 1's vaginal area. Housekeeper 1 told Resident 2 to get out of the room. DON 1 stated Resident 2 had a history of going into other residents' rooms. On 5/9/2022 at 10:00 a.m., during an interview, Housekeeper 1 stated she remembered the incident she witnessed on 1/1/2021. Housekeeper 1 stated it was early morning, around 6 a.m. and she was starting her shift, when she saw Resident 2 standing over Resident 1 with his hand on her vaginal area. Housekeeper 1 stated she told Resident 2 to get out of the room and brought him to Registered Nurse Supervisor 1 (RNS 1) and told him what she saw. On 5/9/2022 at 11:15 a.m., during an interview, RNS 1 stated he no longer worked at the facility but remembered the incident with Resident 2. On 5/10/2022 at11:30 a.m., during an interview, the Administrator (ADM) stated he was unaware of Resident 2's history of sexually inappropriate behavior. The ADM stated it was the responsibility of the staff to supervise and protect the residents and the facility failed to do that with regards to the 1/1/2021 incident that occurred between Residents 1 and 2. A review of the policy and procedure titled, "Abuse Prevention Program," revised 12/2016, indicated it is the policy of the facility to protect its residents from abuse by anyone. The facility failed to ensure Resident 1, who had severely impaired cognition, had the right to be free from sexual abuse from Resident 2. On 1/1/2021, at 6 a.m. staff observed Resident 1's body exposed, and Resident 2, a male, was touching Resident 1's vagina. As a result, Resident 1, who has severely impaired cognition and medical condition was sexually abused by Resident 2. An individual who was subjected to sexual abuse has lifetime physical pain and psychological effects including feelings of hopelessness, helplessness and humiliation. 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.