Other·September 14, 2023

§483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 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)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. §483.12(c) Reporting of Alleged Violations. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. §483.12(c)(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. §483.12(c) Investigate/Prevent/Correct Alleged Violation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(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. HSC 1418.91 Abuse Reporting (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. § 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 7/28/2023, the California Department of Public (CDPH) received an anonymous complaint alleging the facility was dis-enrolling residents from Medicare HMO to Medicare for financial gain. On 7/28/2023, CDPH conducted an unannounced complaint investigation. During the investigation, it was discovered Resident 1 and Resident 2 were being physically restrained in their wheelchairs with a bedsheet to prevent the residents from falling. The facility failed to: 1. Ensure Resident 1 and Resident 2 were free from the use of physical restraints for discipline or staff convenience. 2. Adhere to the facility’s policy and procedure (P&P) to report all abuse allegations timely to CDPH. 3. Investigate the alleged abuse for Resident 1 and Resident 2. 4. Protect Resident 1 and Resident 2 from Licensed Vocational Nurse (LVN) 1, who continued to work at the facility after the abuse incident. As a result, Resident 1 and Resident 2 were physically restrained to their wheelchairs with a bedsheet to prevent the residents from falling, inhibiting Resident 1’s and Resident 2’s freedom of movement. This failure resulted in unidentified abuse in the facility. a. A review of Resident 1’s Admission Record, the record indicated Resident 1, was an 82 year-old female, who was originally admitted to the facility on 6/30/2023 with diagnoses that included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 1’s History and Physical (H&P), dated 7/1/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had a history of encephalopathy (brain disease that alters brain function or structure causing a decline in the ability to reason and concentrate, memory loss, personality change, seizures, and twitching). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/3/2023, the MDS indicated Resident 1 had minimal difficulty in hearing, could sometimes make herself be understood and sometimes had the ability to understand others. The MDS indicated Resident 1’s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired, and the resident had short term and long-term memory problems. The MDS indicated Resident 1 required extensive assistance with locomotion on and off the unit, bed mobility and transfers. b. A review of Resident 2’s Admission Record, the record indicated Resident 2, was a 77 year-old female, who was originally admitted to the facility on 2/21/2023 with diagnoses that included vascular dementia (brain damage caused by multiple strokes, causing cognitive difficulty with reasoning and judgment, and in later stages, memory is affected). A review of Resident 2’s H&P, dated 2/24/2023, the H&P indicated Resident 1 did not have the mental capacity to make medical decisions. A review of Resident 2’s MDS, dated 5/30/2023, the MDS indicated Resident 2 had minimal difficulty in hearing, sometimes made herself understood, sometimes had the ability to understand others and her vision was impaired. The MDS indicated Resident 2’s cognitive skills for daily decision making were moderately impaired and had short-term and long-term memory problems. The MDS indicated Resident 2 required extensive assistance for all activities of daily living and was totally dependent on staff for locomotion on and of the unit. During an interview with Payroll Manager (PM) on 7/31/2023 at 9:48 a.m., in the conference room, the PM stated that in the week of 7/2/2023 to 7/9/2023, the Director of Staff Development (DSD) informed her of the alleged abuse incident regarding Resident 1 and 2 being physically restrained. The PM stated Licensed Vocational Nurse (LVN) 1 had residents (Residents 1 and 2) that were at risk for falls and she did not want to watch them or assign a certified nursing assistant (CNA) to watch the residents. The PM stated that was the reason why LVN 1 restrained the residents to their wheelchairs. During an interview with the DSD on 8/1/2023 at 8:58 a.m., in the DSD’s office, the DSD stated CNA 1 informed her of the use of physical restraints on 7/9/2023 via telephone. The DSD stated CNA 1 told her LVN 1 restrained Resident 1 and Resident 2 to their wheelchairs using a sheet. The DSD stated she asked CNA 1 to remove the restraints from Resident 1 and 2. The DSD stated it was important not to use restraints because it was a violation of the residents’ right to be free. The DSD stated she immediately reported the incident to the Director of Nursing (DON) and the Administrator. The DSD stated she did not report the alleged abuse incident to the Department of Public Health (DPH) because the alleged abuse incident happened on her day off and the nurses on duty should have reported it. The DSD stated the nurses on duty must report all alleged abuse. During an interview with Registered Nurse (RN) Supervisor on 8/1/2023 at 9:56 a.m., in the RN Supervisor’s office, RN Supervisor stated LVN 2 and CNA 1 notified her that LVN 1 was planning to restrain some residents. RN Supervisor stated placing restraints on residents was a form of abuse because it inhibited residents from moving at their own will. RN supervisor stated it was important not to restrain a resident because they could become agitated and would irritate their skin. RN Supervisor stated she did not witness residents restrained to their wheelchairs and that was why she did not report it. RN Supervisor stated she would report the alleged abuse only if she saw it. RN Supervisor stated placing restraints on residents was a form of abuse because it inhibited residents from moving at their own will. RN Supervisor stated LVN 1 worked her full shift on the day of the alleged abuse incident, and LVN 1 returned to work after the alleged abuse incident occurred. RN Supervisor stated LVN 1 was not on the schedule to work but she showed up to work. RN Supervisor stated she called the DON to ask what to do with LVN 1 and the DON told her to allow LVN 1 to work. During an interview with LVN 2 on 8/1/2023 at 10:40 a.m., LVN 2 stated she was informed by CNA 1 that two residents had been restrained to their wheelchairs using drawsheets. LVN 2 stated she and the RN Supervisor were told by LVN 1 not to worry because she had taken care of the situation. LVN 2 stated LVN 1 made a hand gesture as to indicating she had tied up the residents. LVN 2 stated restraining residents was considered a type of abuse. LVN 2 stated she did not report the alleged abuse incident because she did not witness the residents restrained to their wheelchairs. LVN 2 stated she was a mandated reporter but did not report the alleged abuse incident and did not know why. LVN 2 stated she did not investigate if the abuse was reported. During an interview with the Director of Nursing (DON) on 8/1/2023 at 11:30 a.m., the DON stated she was notified of the alleged abuse incident the day it occurred (7/9/2023). The DON stated LVN 1 restrained Resident 1 and Resident 2 to their wheelchairs to prevent them from slipping down from the wheelchair. The DON stated LVN 1 restrained the residents and then placed them in the hallway. The DON stated placing residents under restraints was considered abuse. The DON stated she did not report the alleged abuse incident because she did not see it as abuse, and she did not know why. The DON stated LVN 1 was taken off the work schedule but had allowed her to come back to work. The DON stated LVN 1 should not have returned to the facility because it put the residents at risk for abuse. The DON stated the RN supervisor and LVN 2 did not report the alleged abuse incident and they were supposed to report it. The DON stated staff are all mandated reporters and should have reported the incident. During an interview with CNA 1 on 8/7/2023 at 4:10 p.m., CNA 1 stated she observed LVN 1 restrain Resident 1 and Resident 2 to their wheelchairs and placed the residents in the hallway. CNA 1 stated LVN 1 restrained the residents because the shift was short of one CNA, and she did not have a CNA to watch the residents. CNA 1 stated she informed the RN Supervisor and LVN 2 that she saw LVN 1 restrain Resident 1 and Resident 2 to their wheelchairs. CNA 1 stated the RN Supervisor and LVN 2 told her to remove the restraints from residents. CNA 1 stated she removed the restraints from Resident 1 and Resident 2. A review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect and Exploitation “, dated 12/19/2022, the P&P indicated the facility would provide protection for the health, welfare, and rights for each resident by preventing abuse. The P&P indicated the facility would make efforts to ensure all residents are protected from physical and psychosocial harm. The P&P indicated the facility would report all alleged violations to the administrator, state agency, adult protective services and to all other required agencies. The P&P indicated an abuse allegation must be reported immediately, but not after 2 hours after allegation was made. The P&P indicated the facility would conduct an immediate investigation when there’s suspicion of abuse, neglect, or exploitation, or reports of abuse. The P&P indicated that an investigation includes identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. P&P indicated that facility would be able to provide a complete and thorough documentation of the investigation. A review of the facility’s policy and procedure (P&P) titled, Restraint Free Environment”, date 12/19/2022, the P&P indicated that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraints use to circumstances in which the resident has medical symptoms that warrant the se of restraints. The facility failed to: 1. Ensure Resident 1 and Resident 2 were free from the use of physical restraints for discipline or staff convenience. 2. Adhere to the facility’s P&P to report all abuse allegations timely to CDPH. 3. Investigate the alleged abuse for Resident 1 and Resident 2. 4. Protect Resident 1 and Resident 2 from LVN 1, who continued to work at the facility after the abuse incident. As a result, Resident 1 and Resident 2 were physically restrained to their wheelchairs with a bedsheet to prevent the residents from falling, inhibiting Resident 1’s and Resident 2’s freedom of movement. This failure resulted in unidentified abuse in the facility. This violation(s) caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.