Health inspection·December 29, 2022

F603 §483.12(a) 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— 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. Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

F742 §483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that— §483.40(b)(1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. On 11/15/2022 at 9:15 A.M., an unannounced visit was made to the facility to investigate a complaint regarding patient restraints and seclusion. Specifically, involving a sampled patient (Patient 1) who was assessed as not having the capacity to understand and make decisions, required extensive assistance with transferring from bed to chair and locomotion (movement) inside the room, diagnosed with dementia, had a history of major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and was grieving the recent loss of a family member. As a result of the investigation, the California Department of Public Health (CDPH) determined that the facility failed to: 1. Follow the facility’s policy and procedure on “Abuse and Neglect Prohibition Policy" updated in June 2022, when the facility failed to prohibit involuntary seclusion (separation of a patient/resident from other residents or from her/his room or confinement to her/his room [with or without roommates] against the patient's will, or the will of the patient's legal representative) to Patient 1 when Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1 confined (keep someone in a closed space by force) Patient 1 inside the bathroom by placing a bed against the bathroom door to prevent Patient 1 from getting out, for approximately 40 minutes, on 10/28/22. 2. Follow the facility’s policy and procedure, “Socia1 Worker,” dated May 2017 to conduct a clear assessment and develop appropriate treatment plans to identify Patient 1’s psychosocial needs to assist in coping with problems and remedy adjustment concerns, due to a recent family member’s death and an incident of involuntary seclusion. 3. Follow the facility’s policy and procedure on “Comprehensive Plan of Care” updated in December 2016, to develop a care plan that addressed the assessed patient’s individual needs, strengths, and preferences that described the services provided to attain or maintain the patient’s highest practicable physical, mental, and psychosocial well-being due to being confined in the bathroom by LVN 1 and CNA 1 on 10/28/22. These failures resulted in Patient 1 being secluded (hidden or isolated) against her will, resulting in psychosocial harm. Patient 1 verbalized crying, yelling, and calling out for help, feeling scared when doors were closed or being in dark/closed spaces, unable to sleep at night, and feeling terrified. A review of Patient 1's admission record indicated the female patient, 66 years old, was admitted to the facility on 3/4/2021 and readmitted on 11/9/2022 with diagnoses including chronic obstructive pulmonary disease (COPD-disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Patient 1's History and Physical (H&P) dated 11/11/22, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS; a care assessment tool) dated 9/30/22, indicated Patient 1's cognition was intact. The MDS indicated Patient 1 required extensive (means when a patient requires weight bearing support while performing part of an activity), one person assistance during transfers, toilet use, dressing, locomotion in the unit, and personal hygiene. A review of Patient 1's telephone physician orders dated 10/28/22 timed at 5:19 PM, indicated to transfer to an acute care hospital for evaluation due to severe feeling of sadness secondary to death of a family member. A review of Patient 1’s care plan dated 10/28/22 indicated Patient 1 allegedly reported that she was isolated in the room. The goal of the care plan indicated Patient 1 will not have ill effect related to the alleged incident of being isolated in the room. The care plan interventions included 72 hours [10/28/22 to 10/30/22] monitoring for emotional distress regarding the allegation that she was isolated to the room, head toe to assessment for presence of swelling, bruises and redness; psychologist (a professional that have the professional training and clinical skills to help people learn to cope more effectively with life issues and mental health problems) and psychiatrist (a medical doctor who specializes in the mental health field that can prescribe medications to treat mental illness) consult; social worker visits for 72 hours to check any emotional distress. The care plan did not indicate an individualized interdisciplinary approach that would address Patient 1’s behaviors and fears after being confined by LVN 1 and CNA 1 inside the bathroom. A review of Patient 1's late entry Psychosocial Note dated 10/26/22 timed at 9 AM, indicated the social worker received a call from Patient 1's responsible party about Patient 1's family member's death. The Note indicated the funeral service would be on 10/28/22 at 2 PM. The Note indicated Patient 1 expressed sadness and episodes of crying. The Note further indicated Patient 1 would be referred to a follow up psychology consult. A review of Patient 1's Licensed Nurses Notes indicated the following information: a. On 10/28/22 at 8:03 PM-Physician 1 ordered for Patient 1 to be transferred to the acute hospital for evaluation due to sadness. The Progress Notes indicated Patient 1 would be transferred to the acute hospital the next day (10/29/22). b. On 10/28/222 at 8:20 PM- Patient 1 came back at 4:30 PM from attending the family member's funeral. The note indicated Patient 1 looked sad. A review of the facility's Final Investigation Report Conclusion, dated 11/2/22, indicated the following information: "On 10-28-2022, at approximately 7:07 am, Patient 1 reported to the Director of Staff Development (DSD) she was locked (confined) in her closet last night by a staff member. The DSD inquired to clarify the incident, then immediately reported the allegation to both the ADM and Director of Nursing. He (DSD) reported Patient 1 alleged her charge nurse, LVN 1 locked her in the closet last night. She (Patient 1) stated she was locked in a dark room and was not able to get out. Per LVN 1 and CNA 1, the resident (Patient 1) had been very restless and agitated throughout the 11 pm to 7 am shift. Further stated she (Patient 1) did not sleep at night and was wandering throughout the facility the entire shift (11 pm to 7 am). At one point, the resident (Patient 1) attempted to elope out (walk out without notice) of the facility, and it was at that point LVN 1 and CNA 1 took her (Patient 1) to her room. Patient 1, because she would not stay in her room, she (Patient 1) alleged LVN 1 locked her inside a closet. Several interviews were conducted with Patient 1, and her story remained consistent. Patient 1, stated she was locked in the closet and was unable to get out. Patient 1 stated she (Patient 1) tried to get out for a while, but she was not able to. Patient 1 stated "I know it was LVN 1 who did this to me, that bastard." Patient 1 was not able to tell how she eventually got out of the closet, nor the approximate time this alleged incident occurred." The same review of the Final Investigation Report Conclusion dated 11/2/22 above, further indicated, " Patient 2 (Patient 1's roommate) stated Patient 1 was "locked" in the bathroom. She (Patient 2) stated she witnessed staff place the bed up against the bathroom door, and she (Patient 2) believes the patient (Patient 1) was in there. She (Patient 2) stated she heard noises coming from the bathroom as if someone was trying to get out. Patient 2 showed me (Administrator) where she claimed two (facility) staff members placed a bed against the bathroom door. She (Patient 2) stated the resident (Patient 1) had disappeared while the bed was against the door. CNA 2 stated she entered the room and witnessed LVN 1 and CNA 1, placing the bed against the bathroom door with the resident (Patient 1) already in the bathroom. She (CNA 2) stated they told her to turn her head and act like she did not see anything." A review of Patient 1's acute hospital's records indicated Patient 1 was admitted to the acute psychiatric hospital on 10/29/22 timed at 2:49 PM, with chief complaints of psychosis (used to describe conditions that affect the mind, where there has been some loss of contact with reality), acute (sudden onset) anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), depression, and agitation (a state of excitement, disturbance, or worry). The acute hospital record's Psychiatric Evaluation dated 10/30/22, indicated Patient 1 was placed on 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) for DTO (danger to others) and transferred to the acute hospital for inpatient psychiatric treatment. The evaluation stated Patient 1 was irritable and guarded. A review of Patient 1’s physician orders indicated Patient was admitted back to the facility on 11/9/22 (11 days). On 11/15/22 at 9:25 AM, during an interview with the Director of Nursing (DON), the DON stated during the interviews with CNA 2 and Patient 2, both stated that LVN 1 and CNA 1 "locked (confined)" Patient 1 in the bathroom on 10/28/22, by pushing the bed in front of the bathroom door. The DON stated that the incident was witnessed by CNA 2 and Patient 1's roommate, Patient 2. The DON stated involuntary seclusion is not right because it is a form of abuse and can cause emotional stress, trauma, and the incident can occur in the victim's mind, time and again. The DON stated if staff were unable to redirect patient from leaving the facility, the appropriate intervention for staff is to place the patient on one-to-one supervision (closely monitor), provide as needed medications such as Ativan (anti-anxiety medication) as ordered by the physician, inform the attending physician (Physician 1), and the patient's responsible party, complete an "SBAR (Situation, Background, Assessment and Recommendation." The DON stated if any of the implemented interventions did not work, the facility staff should call 9-1-1 emergency services. An observation of the facility's surveillance video on 11/15/22 at 10:20 AM, in the presence of the ADM indicated the following information dated 10/28/22: a. Timestamped at 5: 21 AM: Patient 1 attempted to exit the facility's front door (wheeling herself). b. Timestamped at 5:23 AM: LVN 1, accompanied by CNA 1 was seen wheeling Patient 1 in her wheelchair back to her room. c. Timestamped at 5:24 AM: CNA 2 was seen walking towards Patient 1's room and went inside the room. d. Timestamped at 5:26 AM: LVN 1, CNA 1, and CNA 2 was seen going out of Patient 1's room. e. Timestamped at 6 AM: CNA 1 and CNA 2 was seen walking back towards Patient 1's room and went back inside Patient 1's room. f. Timestamped at 6:02 AM: LVN 1 was seen walking towards Patient 1's room and entered Patient 1's room. g. Timestamped at 6:03 AM: LVN 1, CNA 1, and CNA 2 was seen exiting Patient 1's room together (40 minutes from 5:23 AM when LVN 1 and CNA 1 was seen wheeling Patient 1 to her room). h. Timestamped at 6:10 AM: Patient 1 was seen wheeling herself out of the room. On 11/15/22 at 10:35 AM, during the observation of the facility's surveillance video and concurrent interview of the ADM, the ADM stated that the incident of Patient 1 being confined in the bathroom inside Patient 1's room happened on 10/28/22 between the hours of 5:23 AM and 6:03 AM. On 11/15/22 at 11:05 AM, (6 days after returning from the acute hospital) during an interview with Patient 1, Patient 1 stated one of her family members died and she was going to a funeral on that day (10/28/22). Patient 1 stated before going to her family member's funeral, during the early morning of 10/28/22, LVN 1 "locked" her in the bathroom, inside her room. Patient 1 stated, "It was dark, very dark." Patient 1 stated she was inside the bathroom for "a long time." Patien