Health inspection·June 21, 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. § 72315 - Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. § 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. On 4/29/2024 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 1 and Resident 2 had physical altercation. On 5/9/2024, CDPH conducted an unannounced visit to the facility to investigate the FRI allegations. Upon investigation, CDPH determined the facility did not protect Resident 1 right to be free from Resident 2's physical abuse. The facility failed to: 1. Ensure Resident 1, who had a history of aggressive behavior toward residents and staff and on 4/18/2024 was sent out to a general acute care hospital (GACH) on 5150 (temporary, involuntary psychiatric commitment of residents who present a danger to themselves or others due to signs of mental illness) hold, was not placed in the same room with Resident 2 upon re-admission to the facility on 4/26/2024. 2. Ensure Resident 1 was assessed upon re-admission to the facility on 4/26/2024 and ongoing for the appropriateness of a placement in the same room with Resident 2 to prevent possible altercation between both residents per facility's policy and procedure (P&P) titled, "Abuse-Prevention, Screening, & Training Program." 3. Provide Resident 2 with 1:1 sitter (constant observation by a staff member for the residents and companions safety) to prevent Resident 2 from altercation with other residents per care plan titled, "Alleged altercation per another roommate (Resident 3) on 4/11/2024." 4. Ensure Resident 3 was not subjected to Resident 2's aggressive outburst by throwing a walker toward Resident 3's direction and punching him on the forehead on 4/11/2024. As a result, Resident 2 punched Resident 1 in the face leading Resident 1 to fall on the floor. Resident 1 sustained a left upper eye lid laceration (skin cut) and skin tears (traumatic wounds that may result from a variety of mechanical forces such as falls) on a right forearm (arm area between the elbow and wrist). Resident 1 was transferred to GACH on 4/27/2024 for evaluation of head trauma. A review of Resident 1's Admission Record indicated Resident 1, a 71 year old male, initially was admitted to the facility on 3/8/2024 and readmitted on 4/26/2024 with diagnoses including paranoid schizophrenia (involves delusions [false beliefs], hallucinations [hearing or seeing things that do not exist), unusual physical behavior, disorganized (abnormal thought process, thinking or speech) and bipolar disorder (a mental illness that causes extreme shifts in a person's mood, energy, activity levels, and concentration). A review of Resident 1's History and Physical (H&P) dated 4/26/2024, indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 5/3/2024, indicated Resident 1 had a moderate impairment in cognitive (relating to the process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, toileting, hygiene, and showering/bathing. A review of Resident 2's Admission Record indicated Resident 2, a 43-year-old male, originally admitted to the facility on 4/5/2024 and readmitted to the facility on 4/22/2024 with diagnoses including paranoid schizophrenia suicidal ideations (suicidal thoughts or ideas), restlessness, agitation, and violent behavior. A review of Resident 2's H&P dated 4/14/2024, indicated Resident 2 was able to make decisions for activities of daily living. A review of Resident 2's MDS dated 4/27/2024, indicated Resident 2 had a moderate impairment in cognitive skills for daily decision-making. with oral hygiene, toileting, hygiene, and showering/bathing. A review of Resident 1's care plan titled, "Resident has a behavior problem: Defecating and urinating on a floor," initiated on 3/14/2024, indicated the goal for Resident 1 was to have fewer behavioral episodes weekly by the target date 6/15/2024. The care plan indicated the interventions included to intervene as necessary to protect the rights and safety of others, remove Resident 1 from the situation (unspecified), to take the resident to alternative location as needed, monitor behavior episodes, and attempt to determine underlying cause, and consider location, time of day, person involved and situation. A review of Resident 1's Nursing Progress Notes (NPN) dated 4/18/2024 and timed at 7:32 a.m., indicated Resident 1 tried to get out of the facility, was physically aggressive toward staff when redirected, pacing (walk at a steady and consistent speed back and forth) the entire night and making sexual comments to staff. A review of Resident 1's NPN dated 4/18/2024 and timed at 2:02 p.m., indicated Resident 1 was on monitoring for increased agitation, verbal, and physical aggression. The NPN indicated Resident 1 was not cooperative with care and refused medication. Resident 1 was sent out to a GACH on 5150 hold. A review of Resident 1's Admission record dated 4/26/2024, indicated Resident 1 was re-admitted back to the facility from the GACH and was placed in the same room with Resident 2. A review of Resident 1's change of condition ([COC]-a sudden change from the resident's baseline) note dated 4/27/2024, indicated around 4:15 a.m., Resident 1 was observed sitting on the floor at the foot of his bed and leaning with his back against the wall. The COC indicated Resident 1 verbalized Resident 2 hit him on the face and he fell on the floor. The COC indicated Resident 1 sustained a left upper eye lid cut and the right lower arm skin tear from the fall. A review of Resident 1's Physician's Order Summary Report dated 4/27/2024, indicated the following orders: 1. Cleanse left upper eyelid cut with Normal Saline (cleansing solution) gently pat dry, then leave it open to air every day and as need daily for 14 days. 2.Cleanse skin tear to the right lower dorsal (back) arm with Normal Saline gently pat dry then cover with foam dressing daily and as needed for 14 days. 3.Computerized Tomography scan ([CT]- diagnostic imaging procedure) of the head. A review of Resident 1's GACH Emergency Department (ED) note dated 4/27/2024, indicated Resident 1 was brought in by ambulance from the facility for evaluation of head injury status post (after) assault (physical attack). The ED note indicated, Resident 1 was punched in the face five times, mainly around the left eye, which caused Resident 1 to fall on the ground. The ED note indicated, Resident 1 hit his head on the wall, slid down and fell, landing on his right elbow on the floor. The ED note indicated, Resident 1 experienced the left eye pain, left eye swelling, and right elbow pain. A review of Resident 1's NPN dated 4/30/2024, indicated Resident 1 had the left periorbital (around the eye) swelling with discoloration, left upper eyelid cut and the right forearm multiple skin tears. During a review of Resident 2's care plan titled, "Alleged altercation per another roommate (Resident 3) on 4/11/2024," initiated on 4/11/2024, indicated the goal for Resident 2 was not to have further altercations with another residents by target date of 7/4/2024. The care plan intervention included to continue to provide 1:1 sitter (constant observation by a staff member for the residents and companions safety) until Resident 2 discharged, administer medication as ordered, send to the hospital for behavior management, and separate Resident 2 and Resident 3 immediately to prevent further altercation. During a review of Resident 2's COC dated 4/11/2024, indicated Resident 2 took Resident 3's walker threw the walker toward Resident 3's direction and punched him on the forehead. The COC indicated, the facility informed the psychiatrist (a physician specialized in mental illness) and had an order to transfer Resident 2 to a GACH. During a review of Resident 2's GACH record, dated 4/12/2024, indicated Resident 2 was presented on a 5150 hold for danger to others. The GACH's clinical record indicated Resident 2 was placed on 5150 hold for "aggression towards other residents." The GACH's record indicated, upon one-to-one interaction with nursing staff on admission to the GAHC Resident 2 remained silent, refused to cooperate with admission process, and remained unpredictable for violence. During a review of Resident 2's Psychiatric Progress Note from the GACH, dated 4/20/2024, indicated, Resident 2 was still very disorganized in thought process and was unable to engage in any reality-based conversation. The Psychiatric Progress Note indicated Resident 1 will continue to require ongoing psychiatric management in a structured environment such as GACH. A review of Resident 2's COC dated 4/27/2024 indicated Resident 2 had alleged physical altercation with Resident 1, his roommate. The COC indicated when Resident 2 was asked what happened he did not respond. The COC indicated Resident 2 was placed on 1:1 sitter observation for safety. A review of Resident 2's care plan titled, "Resident 2 had a behavior problem of refusing all care and medications, spitting on the floor and spreading feces on the facility walls," initiated on 4/25/2024, indicated the goal for Resident 2 was to have fewer episodes of refusing care, spitting on the floor, refusing medications, and spreading feces on the wall daily/weekly by a target date of 7/04/2024. The care plan intervention included to monitor Resident 2 behavioral episodes and attempt to determine underlying causes, consider location, time of day, persons involved, and situations, and document behavior and potential causes. During an interview on 5/9/2024 at 10:30 a.m., the Social Service Director (SSD) stated Resident 2 had another altercation with another resident (Resident 3) on 4/11/2024 when Resident 2 took Resident 3's walker in the hallway and threw it towards Resident 3's direction. The SSD stated Resident 2 was sent out to the hospital via Psychiatric Emergency Team ([PET] a mobile team operated by psychiatric hospitals) on 5150 hold. The SSD stated Resident 2 was physically violent toward Resident 1. The SSD stated Resident 1 had a bruise on his left eye at that time. The SSD stated upon police arrival on 4/27/2024 to the facility, Resident 1 wanted to press charges against Resident 2, and Resident 2 was detained by the police. During an interview on 5/9/2024 at 10:40 a.m., a Certified Nursing Assistant (CNA 1) stated Resident 2 was very short tempered and shout at the facility's staff. CNA 1 stated, Resident 2 was very hard to take care of because he was getting mad when he was asked a question. CNA 1 stated, it was not safe for Resident 2's door to be close for safety. CNA 1 stated, he should have done more frequent visual check every 1-2 hours and get another nurse to check Resident 2 for safety. During a concurrent observation and interview on 5/9/2024 at 11:08 a.m., in Resident 1's room, Resident 1 with dry dark scabs on his right forearm and light discoloration under his left eyelid. Resident 1 stated, he remembered about the alleged incident with Resident 2. Resident 1 stated, on the day of the incident (4/27/2024), Resident 1 used the bathroom and on the way back to his bed he noticed Resident 2 was closing the room door and started punching Resident 1's face. Resident 1 was observed with increased tone of voice. Resident 1 stated he did not feel safe and felt scared when he thought about the incident. During an interview on 5/9/2024 at 11:40 a.m. CNA 2 stated on the days she took care of Resident 2 (dates unknown), the resident was getting angry and was aggressive toward other residents and staff. During an interview on 5/9/2024 at 11:56 a.m., the Registered Nurse Supervisor (RNS 1) stated based on Resident 2's diagnoses of mental illnesses and history of aggressive behavior toward other residents, the facility staff should make frequent rounds every hour or two hours and ensure the room door was not close to check on residents' safety and prevent possible altercation between Resident 1 and Resident 2. During a phone interview on 5/09/2024 at 12:27 p.m. CNA 3 stated she heard a loud sound, like something fell on the ground on 4/27/2024. CNA 3 stated she ran to check where the sound came from when she reached Resident 1 and 2's room, the door was close. CNA 3 stated, when she attempted to open the door, it was hard to open and felt like someone was pushing against the door. CNA 3 stated she had to call for help to open Resident 1 and Resident 2's room door. CNA 3 stated when the door was opened, she saw Resident 1 was sitting on a floor next to his bed, leaning towards the right side of his body. CNA 3 stated Resident 2 was standing next to the door. CNA 3 stated, Resident 1 looked very scared. CNA 3 stated Resident 1 verbalized Resident 2 punched him. CNA 3 stated Resident 2's facial expression looked like the one that conveys anger or frustration. CNA 3 stated on 4/26/2024 around 11 p.m. Resident 1 was observed sleeping in bed. CNA 3 stated Resident 2 was observed pacing inside the room and outside of the room. CNA 3 stated the last time she checked on Resident 1 and Resident 2 was 11 pm. CNA 3 stated Resident 2 had no 1:1 sitter on 4/27/2024 to prevent the altercation between Resident 1 and Resident 2. During a phone interview on 5/9/2024 at 12:50 p.m. the Licensed Vocational Nurse (LVN 1) stated when they were trying to open Resident 2's room door it was hard to open as if someone was pushing against it. LVN 1 stated when the door was finally opened Resident 1 was observed sitting on the floor. LVN 1 stated upon assessment Resident 1 had a skin tear on his right lower arm, and laceration of his left eyelid approximately 1.5 centimeters ([cm] a unit of measurement) long on his left eyelid. LVN 1 stated Resident 1 and Resident 2 last checked was around between 12m.n. and 1 a.m. on 4/27/2024. LVN 1 stated the incident happened around 4 a.m. on 4/27/2024. LVN 1 stated, staff should make rounds often at least every 2 hours especially Resident 1 and 2 who have history of aggressive behavior toward other residents and staff, and to assess and monitor their behavior such as anxiety, restlessness, verbal agitation, or pacing and to ensure safety of both residents. During a concurrent interview and record review on 5/13/2024 at 9:10 a.m., the Director of Nursing Service (DON), stated Resident 2 had a history of alleged physical aggression towards other residents when Resident 2 threw a walker towards the direction of Resident 3 and punched Resident 3 in the hallway. The DON stated based on Resident 2's history of physical aggression toward other residents the facility should have assess and consider wh