Other·May 31, 2024

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 §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. WIC 15630(a) Any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter. (b) (1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section 15658, within two working days. (A) If the suspected or alleged abuse is physical abuse, as defined in Section 15610.63, and the abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the suspected abuse results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately, but also no later than within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. (ii) If the suspected abuse does not result in serious bodily injury, a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. On 4/17/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about abuse. The facility failed to: 1. Ensure Resident 1 had the right to be free from psychological (mental or emotional) abuse (the use of verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation [the feeling of being ashamed or losing respect to own self], intimidation, fear, shame, agitation, or degradation) when on 4/7/2024 between 2:40 p.m. to 2:50 p.m., Certified Nursing Assistant 2 (CNA 2) and CNA 3 witnessed CNA 1 placed and dropped potato chips on the floor and instructed Resident 1 to eat them. 2. Report the allegation of staff to resident abuse to CDPH timely. On 4/8/2024, CNA 3 reported the allegation of abuse to the Director of Nursing (DON), one day after the incident was observed. The DON reported the allegation to CDPH on 4/9/2024, two days after the allegation of abuse was made. As a result, based on the Reasonable Person Concept (refers to a tool to assist the survey team’s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident’s position), due to Resident 1’s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to abuse may have psychological effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation. A review of Resident 1’s Admission Record indicated the facility admitted the 33-year-old male resident on 8/8/2023 with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and chronic bronchitis (a long-term inflammation of the bronchi [the large air passages that lead to the lungs]). A review of Resident 1’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 2/14/2024, indicated the resident’s cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills was moderately impaired. The Mood section indicated Resident 1 had little interest or pleasure in doing things and feeling down, depressed, or hopeless. A review of Resident 1’s Psychiatric Progress Notes, dated 4/8/2024, indicated the resident had poor insight and poor judgment. A review of the facility-provided 5-Day Post Event Report, dated 4/9/2024, indicated the allegation of abuse happened on 4/7/2024. The report indicated the facility was made aware of the alleged abuse on 4/9/2024 at 4:30 p.m. and the facility initiated an investigation. The report indicated that CNA 1 made statements that contributed to Resident 1 eating the potato chips that CNA 1 dropped and placed on the floor. A review of Resident 1’s Interdisciplinary Team (IDT) Notes, dated 4/16/2024, indicated the allegation of abuse by a facility staff happened on 4/7/2024. On 4/17/2024 at 9:41 a.m., during an interview, Resident 1 stated CNA 2 had some potato chips and the resident had asked for a piece. Resident 1 stated CNA 1 dropped potato chips on the floor and told the resident to eat them. Resident 1 stated that several CNAs were at the nurse station and witnessed CNA 1 dropped the potato chips on the floor for Resident 1 to eat. On 4/17/2024 at 9:53 a.m., during an interview, CNA 2 stated that on 4/7/2024 at 2:40 p.m., he offered CNA 1 and CNA 3 some potato chips that he was eating at the nurse station 1 north side. CNA 2 stated Resident 1 asked for some potato chips and saw CNA 1 dropped some potato chips on the floor and asked Resident 1 to eat them. CNA 2 stated that CNA 1 dropped more potato chips on the floor and again told Resident 1 that the potato chips on the floor were for the resident. CNA 2 stated that he did not report CNA 1’s actions towards Resident 1. CNA 2 stated Resident 1 had the potential for more emotional abuse and had the potential to feel less of a person. On 4/17/2024 at 10:44 a.m., during a telephone interview, regarding the incident on 4/7/2024, CNA 3 stated that he saw CNA 1 dropped potato chips on the floor after Resident 1 had asked for some potato chips. CNA 3 stated that CNA 1 dropped more potato chips on the floor and told Resident 1 that the potato chips were for the resident. CNA 3 stated that CNA 1 laughed at Resident 1 as the resident picked up the potato chips from the floor. CNA 3 stated that he reported the allegation of abuse on 4/8/2024 to the DON. CNA 3 stated that Resident 1 had the potential for more abuse and disrespect. CNA 3 stated that Resident 1 had the potential to feel less of a person. On 4/17/2024 at 11:11 a.m. and 11:38 a.m., attempted to contact CNA 1 but he did not answer and did not return the call. On 4/17/2024 at 12:16 p.m., during an interview, the DON stated that the allegation of abuse happened on 4/7/2024. The DON stated that CNA 3 reported the allegation to him on 4/8/2024. The DON stated that the facility staff should intervene to stop the behavior, remove the resident from the area where CNA 1 was located, and report the incident to the supervisor. The DON stated that facility staff should report allegations of abuse immediately and report to CDPH within 24 hours if there was no significant injury to the resident. The DON stated that he reported the allegation of abuse to CDPH on 4/9/2024. The DON stated that allegations of abuse not being reported on time to CDPH had the potential for residents to sustain unnecessary psychological harm and affect the resident’s dignity and respect leading to a potential for social withdrawal. A review of the facility’s policy and procedure on Patient Rights, revised on 3/1/2023, indicated that the facility follows rules and guidelines set forth by the California Department of Mental Health and Patient Rights advocates with regards to resident rights which included the right to be free from abuse and neglect. A review of the facility’s policy and procedure titled, “Abuse Prevention – Employee,” revised on 12/6/2022, indicated the facility will maintain a work and living environment that is professional and free from threat and / or occurrence of harassment, abuse (verbal, physical, emotional, or sexual), neglect, corporal punishment, involuntary seclusion, and misappropriation of property. The policy indicated that providing a safe environment for residents was one of the most basic and essential duties of the facility and its employees. A review of the facility’s policy and procedure titled, “Abuse Reporting – Dependent Adults,” revised on 12/6/2022, indicated the DON, program manager, or incident report coordinator will be responsible for reporting all suspected incidents of dependent adult abuse as soon as possible by phone to the Department of Public Social Services (DPSS). The Reporting Procedures section indicated that if the reportable event does not result in serious bodily injury, the Administrator (ADM) or designee will make a written report to the local Ombudsman, the California Department of Public Health, and the local law enforcement agency within 24 hours of the observation, knowledge, or suspicion of abuse. The facility failed to: 1. Ensure Resident 1 had the right to be free from psychological abuse when on 4/7/2024 between 2:40 p.m. to 2:50 p.m., CNA 2 and CNA 3 witnessed CNA 1 placed and dropped potato chips on the floor and instructed Resident 1 to eat them. 2. Report the allegation of staff to resident abuse to CDPH timely. On 4/8/2024, CNA 3 reported the allegation of abuse to the DON, one day after the incident was observed. The DON reported the allegation to CDPH on 4/9/2024, two days after the allegation of abuse was made. As a result, based on the Reasonable Person Concept, due to Resident 1’s impaired cognition and medical condition, an individual subjected to abuse may have 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 to Resident 1.