Health inspection·September 16, 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 42 CFR § 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. (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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 8/9/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about sexual abuse. The facility failed to ensure Resident 1, who was legally blind and had severely impaired cognition (mental action or process of acquiring knowledge and understanding), was protected and kept free from sexual abuse by Resident 2, and that the incident of sexual abuse was timely reported to CDPH. On 6/16/2022 at 3:00 a.m., Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 on top of Resident 1. Resident 2's pants were down to his knees while humping Resident 1's leg. Resident 1 was not evaluated by the facility for capacity to consent to sexual activity, and Resident 1 remained roommates in the same room as Resident 2 until 6/23/2022. The facility reported the sexual abuse incident to CDPH seven days later, on 6/23/2022. As a result, Resident 1 was subjected to a non-consensual sexual act by Resident 2 and continued to be at risk for further harm until Resident 2 was no longer Resident 1’s roommate seven days after the initial incident. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 9/19/2021, with diagnoses including epileptic seizures (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body), difficulty in walking and legal blindness. A review of Resident 1's History and Physical dated 9/20/2021 indicated the resident did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/23/2022 indicated Resident 1's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 1 required limited assistance from staff for moving in bed, transferring from bed to chair, toilet use, and personal hygiene. A review of Resident 1's Change of Condition (COC) Evaluation Form (document that describes a change in the resident's health or functioning) dated 6/23/2022 indicated that Resident 1 was involved in an alleged inappropriate sexual movement against his legs by Resident 2 (referring to the 6/16/2022 incident). A review of Resident 1's Psychiatrist Notes (Psych Notes) dated 7/06/2022 indicated, the resident was diagnosed with senile dementia (other name for Alzheimer's disease - a progressive disease that destroys memory and other important mental functions) on 12/2020. The Psych Notes indicated that Resident 1 had an incident in the facility on 6/16/2022 when CNA 1 saw another resident (Resident 2) at 3:00 a.m., on his bed naked and humping Resident 1's legs. A review of Resident 2's Admission Record indicated the facility admitted the resident on 10/15/2021 with diagnoses including displaced fracture of the right femur (broken thigh bone), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and psychosis (a condition that affects the way your brain processes information and causes you to lose touch with reality, and you might see, hear, or believe things that are not real). A review of Resident 2's History and Physical dated 10/18/2021 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2's MDS dated 4/21/2022 indicated Resident 2's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 required limited assistance from staff for moving in bed, transferring from bed to chair, toilet use, and personal hygiene. A review of Residents 2's COC dated 6/23/2022 indicated a facility staff witnessed Resident 2 doing inappropriate sexual behavior towards Resident 1 (referring to the 6/16/2022 incident) and staff separated both residents. The COC indicated the physician was notified on 6/23/22 at 7:07 p.m. A review of Resident 2's Physician Order dated 6/23/22 at 7:27 p.m., indicated an order to monitor Resident 2 for any sexual behavior every shift. A review of Resident 2's Psychiatry Note dated 6/30/2022, indicated during assessment, Resident 2 asked the nurse to come to bed with him. The Psychiatry Note also indicated the resident has Obsessive Compulsive Disease (OCD - excessive thoughts that lead to repetitive behaviors) Hypersexual Behaviors. The note indicated an intervention to continue 1:1 supervision for at least two days and Resident 2 was started on fluvoxamine (a medication used to decrease thoughts that are unwanted or that don't go away and helps reduce the urge to perform repeated task) 25 milligrams (mg - unit of measure) for five days, then 50 mg daily for OCD hypersexual intervention if wandering or pacing behavior observed, to initiate visual supervision. During an interview on 6/29/22 at 12:50 p.m., the Administrator (Admin) stated that CNA 1 witnessed sexually inappropriate behaviors between Resident 1 and Resident 2 on 6/16/2022 at approximately 3:00 a.m. The Admin stated that CNA 1 reported their observations to LVN 1, who reported the allegation to RN 1 between 5:00 a.m. and 6:00 a.m. The Admin stated that neither CNA 1, LVN 1, or RN 1 reported the incident to facility leadership. The Admin stated facility leadership did not become aware of the allegation of sexually inappropriate behavior between Resident 1 and Resident 2 until seven days later on 6/23/22 at approximately 5:15 p.m. During an interview on 8/05/2022 at 1:31 p.m., with Resident 1's Primary Care Physician 1 (PCP 1), PCP 1 stated Resident 1 has baseline dementia that had worsened. PCP 1 stated that Resident 1 cannot give consent for sexual acts given his health conditions. During an interview on 8/05/2022 at 2:45 p.m., CNA 1 stated she was making rounds at 3:00 a.m. on 6/16/22, when she noticed that Resident 1 and Resident 2's room door was closed. CNA 1 stated that when she opened the door, she saw Resident 2 in Resident 1's bed. CNA 1 stated that Resident 2's pants was down to his knees, and he was pushing his genitals in the leg of Resident 1 while Resident 1 was lying in bed, awake, looking at the ceiling and not making any sound. CNA 1 stated Resident 2 was saying, "come on, come on" while humping Resident 1's leg. CNA 1 stated she separated Resident 2 from Resident 1 before she left the room and reported the incident to LVN 1. CNA 1 further stated that she saw Resident 2 approximately four weeks ago lying in Resident 1's bed beside Resident 1 with clothes on and she did not report the incident. During an interview on 8/05/2022 at 6:48 p.m., with PCP 2 (Resident 2’s PCP), PCP 2 stated Resident 2 cannot give consent to sexual acts. During an interview on 8/06/2022 at 8:17 a.m., LVN 1 stated that on 6/16/2022 around 5:00 a.m., CNA 1 informed her that Resident 2 was found in Resident 1's bed. LVN 1 stated she reported the incident to RN 1. LVN 1 stated RN 1 told her to endorse the incident to the oncoming 7:00 a.m. to 3:00 p.m. shift. LVN 1 stated she did not document the incident in either Resident 1 or Resident 2's medical record. LVN 1 stated that she assumed that RN 1 would document the alleged sexual abuse between Resident 1 and Resident 2. LVN 1 stated she should have documented that she received the allegation of sexual abuse from CNA 1, and that she should have also documented that it was reported to RN 1. LVN 1 further went on to state that she was busy at that time and forgot. During an interview on 8/06/2022 at 1:48 p.m. with Resident 1's family member (FM 1), FM 1 stated the facility informed him of the incident on 6/23/2022. FM 1 stated "this is a level of abuse". FM 1 stated he expected that Resident 1 would be taken care of while in the nursing home, and that staff will protect him from any kind of abuse. FM 1 stated he expected them to protect Resident 1 given that he is blind and has dementia. FM 1 stated Resident 1 was not protected from sexual abuse. During an interview on 8/08/2022 at 9:47 a.m., RN 1 stated LVN 1 informed her on 6/16/2022 that Resident 2 was found humping Resident 1's leg with his penis. RN 1 stated that she instructed LVN 1 to endorse the alleged sexual abuse incident to the next shift. RN 1 stated that she was not aware that she had to report for any kinds of allegations of abuse other than physical abuse. During an interview on 8/08/2022 at 11:44 a.m. with Resident 2's Psychiatric Nurse Practitioner (PNP), the PNP stated she saw the resident on 6/30/2022 and upon assessment, Resident 2 was observed sexually harassing the nurse asking her to go to bed with him. The PNP stated Resident 2 was suffering from OCD hypersexual behavior, so she ordered fluvoxamine which is prescribed for OCD as he was exhibiting sexual behaviors. The PNP stated if she had been informed of Resident 2's prior sexual behavior, she could have seen him earlier and might have prevented the incident with Resident 2 and Resident 1 from happening. A review of the facility's policy and procedure titled, "Sexuality Among Residents", dated 11/2012 and reviewed on 02/16/2022, indicated, "It is the policy of the facility to respect the sexual rights of consenting residents, while protecting non-consenting or incompetent residents from the unwanted or unsafe advances of other residents. When it becomes apparent, (either by voicing their desire or observed physical contact), that two residents are engaging in, or about to engage in, a new sexual relationship, not previously assessed and care planned by the Interdisciplinary Team as safe and consensual: C. The Charge Nurse will notify the Director of Nursing and Social Services designee, for further instructions and for follow up by the Interdisciplinary Team. Allegations regarding sexual abuse or assault will be investigated and reported". A review of facility's policy and procedure titled, "Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the Facility", dated 3/2018 and reviewed on 02/16/2022, indicated, "The facility prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident's property. Each resident has the right to be free from abandonment, mental/emotional, isolation, involuntary seclusion, verbal, physical, financial, sexual, neglect, and misappropriation of property. Resident must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. It is presumed that instances of abuse for all residents, even those in coma, can cause physical, harm, pain, or mental anguish. The facility will ensure that all residents are protected from physical or psychosocial harm during and after the investigation. This includes responding immediately with providing a safe environment for residents: a. If the suspected perpetrator is another resident: i. Separate the resident immediately so they do not interact, with each other until circumstances of the reported incident can be determined. 1. If a room change is appropriate, advice residents' families of the change in room location: ii. Increase supervision of the alleged victim and residents, if needed. A review of the facility's policy titled "Reporting Reasonable Suspicion of a Crime in the facility" dated 3/2018 indicated that the Facility will report allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property even if no reasonable suspicion. i. When: 1. Immediately- no later than 2 hours- all abuse (actual, alleged, or potential) OR results in serious bodily injury. 2. No later than 24 hours- all other conduct (actual, alleged, or potential neglect mistreatment, misappropriation of property, and injuries of unknown source) AND did not result in serious bodily injury." The facility failed to ensure Resident 1, who was legally blind and had severely impaired cognition was protected and kept free from sexual abuse by Resident 2 and the incident of sexual abuse was timely reported to CDPH. On 6/16/2022 at 3:00 a.m., CNA 1 witnessed Resident 2 on top of Resident 1, Resident 2's pants were down to his knees while humping Resident 1's leg. Resident 1 was not evaluated by the facility for capacity to consent to sexual activity, and Resident 1 remained roommates in the same room as Resident 2 until 6/23/2022. The facility reported the sexual abuse incident to CDPH seven days later, on 6/23/2022. As a result, Resident 1 was subjected to a non-consensual sexual act by Resident 2 and continued to be at risk for further harm until Resident 2 was no longer Resident 1’s roommate seven days after the initial incident. 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.