Health inspection·August 13, 2024

§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. On 6/28/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about an allegation of resident-to-resident abuse. The facility failed to ensure Resident 6 was free from abuse by Resident 7. On 6/26/2024 at 1 p.m., Certified Nursing Assistant 1 (CNA 1) and CNA 2 heard Resident 6 and Resident 7 screaming at each other and on 6/26/2024 at around at 1:30 p.m., Licensed Vocational Nurse 1 (LVN 1) witnessed Resident 7 punched Resident 6's chest. As a result, Resident 6 was subjected to physical abuse by Resident 7 while under the care of the facility. During a review of Resident 6's Admission Record indicated the facility admitted the 79-year old male resident on 6/14/2023, with diagnoses that included chronic respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood), chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation (when a person's respiratory symptoms significantly worsen) and generalized anxiety disorder (feel extremely worried or nervous more frequently about these and other things, even when there is little or no reason to worry about them). During a review of Resident 6's History and Physical, dated 6/16/2023, indicated Resident 6 had capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/29/2024, indicated Resident 6 had intact cognition (mental action or process of acquiring knowledge and understanding). Resident 6 used walker and wheelchair for mobility. During a review of Resident 6's Change in Condition Evaluation (COC), dated 6/26/2024, indicated Resident 6 had disagreement with Resident 7. The COC indicated on 6/26/2024 at 1:30 p.m., LVN 1 was in front of Resident 6's room when LVN 1 witnessed Resident 7 walked towards the exit and punched Resident 6's upper chest. The COC indicated Resident 7 verbalized that Resident 7 punched Resident 6 because Resident 6 tried to trip Resident 7. The COC indicated Resident 6 was moved to the hallway and Resident 7 stayed in the room. During a review of Resident 6's Progress Note, dated 6/26/2024, timed at 2:56 p.m., indicated that LVN 1 informed Registered Nurse 1 (RN 1) that Resident 6 and Resident 7 had a verbal disagreement that resulted to a physical altercation. During a review of Resident 7's Admission Record indicated the facility admitted the 61-year-old male resident on 6/17/20224, with diagnoses that included alcohol dependence with withdrawal delirium (sudden and severe mental or nervous system changes), palpitations (a skipped, extra, or irregular heartbeat), and shortness of breath. During a review of Resident 7's MDS, dated 6/24/2024, indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's COC dated 6/26/2024, indicated Resident 7 had a physical aggression (violent behavior) towards Resident 6. During a review of Resident 7's Progress Note, dated 6/26/2024, indicated Social Service Director (SSD) was notified that Resident 7 had a verbal disagreement that resulted in a physical altercation (quarrel or fight) with Resident 6. During an interview on 6/28/2024 at 10:33 a.m., CNA 1 stated on 6/26/2024 at 1:30 p.m., CNA 1 was in the hallway outside Resident 6 and Resident 7's right side of door when CNA 1 witnessed Resident 7's right closed fist swung towards Resident 6 who was seated on the wheelchair beside Resident 6's bed, inside the room. CNA 1 stated CNA 1 heard the sound of the hit and when CNA 1 responded, Resident 6 reported getting hit one time in the upper chest close to the neck. CNA 1 stated LVN 1 was in front of Resident 6 and Resident 7's room when it happened. CNA 1 stated LVN 1 took Resident 7 out of the room and CNA 1 stayed with Resident 6. CNA 1 stated Resident 6 initially had no pain but when LVN 1 came back and asked Resident 6, Resident 6 complained of pain. CNA 1 stated Resident 7 reported walking out of the room when Resident 6 tried to trip Resident 7 with Resident 6's foot the reason why Resident 7 verbalized he turned around and hit Resident 6. CNA 1 stated on 6/26/2204 at 1:10 p.m., 20 minutes before the 1:30 p.m. incident, CNA 1 heard Resident 6 and Resident 7's verbal argument and CNA 2 separated Resident 6 and Resident 7. During an interview on 6/28/2024 at 1:14 p.m., CNA 2 stated she was at the other end of Station 2 when CNA 2 heard yelling back and forth and when CNA 2 responded to Resident 6 and Resident 7's room, Resident 6 seated in the wheelchair beside his bed and Resident 7 standing at the foot of his own bed. CNA 2 stated it was at 1p.m., when she heard Resident 6 and Resident 7 yelling. CNA 2 stated there were no room change done at that time. CNA 2 stated if room change was done for Resident 6 and Resident 7, there would be no physical altercation. CNA 2 stated she was aware that there was another altercation that happen at 1:30 p.m. on 6/26/2024 because CNA 2 was still in the Station 2 hallway. During an interview on 6/28/2024 at 3:08 p.m., the Assistant Director of Nursing (ADON) stated on 6/26/2024 ADON was informed that Resident 7 hit Resident 6, but CNA 1 notified her this morning that CNA 1 did not actually saw Resident 7 hit Resident 6. The ADON stated Resident 6 denied getting hit and Resident 7 reported that Resident 7 only tried to hit Resident 6. The ADON stated she was not informed of the verbal incident before the 1:30 p.m. incident. The ADON stated if there was a verbal altercation, they should have a room change. The ADON stated if room change was done, physical altercation could have been prevented. During an interview on 7/3/2024 at 9:28 a.m., LVN 1 stated on 6/26/2024 at 1:30 p.m., LVN 1 came back from lunch break when CNA 2 reported that Resident 6 and Resident 7 screamed at each other. LVN 1 stated she responded to Resident 6 and Resident 7's room but there was no commotion. LVN 1 stated she gave Resident 6 a pain pill and went out of the room. LVN 1 stated when she walked out heard Resident 7 got up from his bed, walked towards the door. LVN 1 stated she turned around and witnessed Resident 7 strike Resident 6 chest area. LVN 1 admitted she witnessed the physical contact and heard the sound of the impact. LVN 1 stated Resident 6 did not block the door. LVN 1 stated Resident 7 reported that Resident 6 tried to trip Resident 7. LVN 1 stated Resident 6 reported that he was hit by Resident 7. LVN 1 stated Resident 7 physically abused Resident 6. LVN 1 stated she reported to Quality Assurance Nurse 1 (QA Nurse 1) and requested a room change so both residents would be separated. LVN 1 stated she did not request a room change for Resident 6 and Resident 7 when CNA 2 notified LVN 1 that both residents screamed at each other because LVN 1 did not witness Resident 6 and Resident 7 yelling at each other. During an interview on 7/3/2024 at 9:48 a.m., Registered Nurse 1 (RN 1) stated she was not informed that Resident 6 and Resident 7 was screaming at each other before the physical contact. During an interview on 7/3/2024 at 10:39 a.m., the ADON stated residents have the right to be free from abuse. The ADON stated it is important for residents to feel safe in the facility. During a review of facility's policy and procedure titled, "Abuse Prevention Program," dated 3/6/2023 indicated, "It is the policy of SNF 1 to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment (a punishment which is intended to cause physical pain to a person), and involuntary seclusion (separation of a resident from other residents against the resident's will, or the will of the resident's legal representative). Resident will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff from other agencies serving the resident, family members or legal guardians, friends, or other individuals. Physical abuse included hitting, slapping, pinching, and kicking. It also includes controlling behavior though corporal punishment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents of their families, or within their hearing distance, regardless of their age, ability to comprehend or disability." The facility failed to ensure Resident 6 was free from abuse by Resident 7. On 6/26/2024 at 1 p.m., CNA 1 and CNA 2 heard Resident 6 and Resident 7 screaming at each other and on 6/26/2024 at around at 1:30 p.m., LVN 1 witnessed Resident 7 punched Resident 6's chest. As a result, Resident 6 was subjected to physical abuse by Resident 7 while under the care of the facility. The above violation had direct or immediate relationship to the health, safety, or security of Resident 6.