Health inspection·October 24, 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 9/3/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging that on 8/31/2024 Resident 1 threw a coffee cup to Resident 2 and on 9/9/2024, CDPH received an FRI alleging Resident 3 hit Resident 4 on the face on 9/6/2024. On 9/9/2024, CDPH conducted an unannounced visit to the facility to investigate FRIs allegations. Upon investigation, CDPH determined the facility did not protect Resident 1 from Resident 2's and Resident 3 from Resident 4's physical abuse. On 8/31/2024 Resident 1 threw a coffee cup to Resident 2 right side of the head which resulted in a skin abrasion. On 9/6/2024 Resident 3 punched Resident 4 in the face. The facility failed to: 1. Ensure a Certified Nursing Assistant (CNA 1) separated Resident 1 and Resident 2 immediately when the two residents were observed arguing over a wheelchair which resulted in Resident 1 throwing a coffee cup to Resident 2's right side of the head. Resident 1 had a recent history of resident-to-resident altercation in June 2024 and Resident 2 had a known aggressive behavior against staff and residents. 2. Protect and prevent Resident 3 from hitting Resident 4 on the face while walking in the hallway on 9/6/2024. As a result, Resident 2 sustained a skin abrasion on the right side of the head and Resident 4 got hit on the face and fell on the floor. A review of Resident 1's Admission Record, indicated Resident 1, a 67-year-old male, was admitted to the facility on 1/17/2024 and readmitted on 7/1/2024 with diagnoses including schizophrenia (serious mental illness that affects how a person thinks, feels and behaves), schizoaffective disorder ( a mental condition characterized by abnormal thought processes and unstable mood) and chronic obstructive pulmonary disease ([COPD], group of lung diseases causing restricted airflow and breathing problems). A review of Resident 1's History and Physical (H&P) dated 7/3/2024, indicated Resident 1 could make needs known but could not make medical decisions due to the diagnosis of schizophrenia. A review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 7/24/2024, indicated Resident 1 was independent with bed mobility, eating, transferring from bed to chair, toileting hygiene and personal hygiene. A review of Resident 1's Change of Condition Evaluation (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember), behavioral, or functional condition) dated 6/21/2024, timed at 7:40 a.m., indicated Resident 1 pushed and hit a resident (unknown) on the chin when the staff was passing coffee in the hallway. A review of Resident 1's COC Evaluation dated 8/31/2024, timed at 7:31 a.m., indicated Resident 1 was receiving coffee in the hallway and saw Resident 2 sat on his (Resident 1's) wheelchair. The COC indicated Resident 1 told Resident 2 to get up and then threw the coffee cup at Resident 2 which hit the right side of Resident 2's head. The COC indicated Resident 2 had a small abrasion on the right side of his head. A review of Resident 1's Care Plan titled, "Aggressive behavior related to schizophrenia" initiated 2/23/2024, indicated care plan's goal for Resident 1 was the resident will not harm self or others. The Care Plan interventions included to intervene before the resident become agitated (a feeling of irritability or mental distress) and remove the resident away from source of distress and engage calmly in conversation. , A review of Resident 1's Care Plan titled "Recent episodes of altercation with another resident" initiated 8/31/2024, the Care Plan goal indicated the resident will not have any changes in mood, behavior, and socialization. The Care Plan's interventions included educating all staff about triggers, de-escalation (to become less dangerous) and signals of the onset of agitation. A review of Resident 2's Admission Record, indicated Resident 2 , a 77- year- old male, was admitted to the facility on 8/7/2024 with diagnoses including bipolar disorder (associated with episodes of mood swings ranging from feeling very low and feeling very high or overactive) and unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities). A review of Resident 2's H&P dated 8/8/2024, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 2's MDS dated 8/14/2024, indicated Resident 2 had severe cognitive impairment and was independent with bed mobility but required set up or clean up assistance (helper sets up or cleans up) with eating and personal hygiene. A review of Resident 2's COC Evaluation dated 8/31/2024, timed at 8:30 a.m., the COC Evaluation indicated Resident 2 was sitting in a wheelchair when Resident 1 told him to get up from the wheelchair and then threw the coffee cup towards Resident 2's right side of the head. A review of Resident 2's Nurses Progress Notes dated 8/18/2024 timed at 9:08 p.m., indicated Resident 2 was verbally aggressive with increased agitation. The Nurses Progress Notes indicated Resident 2 was pacing in and out of his room to the hallways with non-stop swearing while walking back and forth. A review of Resident 2's Nursing Progress Notes dated 8/28/2024, and 8/29/2024, indicated Resident 2 was being monitored for verbal aggression and increased agitation. A review of Resident 2's Care Plan titled, "Resident-to-resident altercation" initiated 8/31/2024, the care plan goal indicated Resident 2 will have no further episodes of resident-to-resident altercation through the review period (11/14/2024). The Care Plan's interventions included to monitor the resident interactions with other residents and encourage group and social activities of choice. During a concurrent observation and interview on 9/9/2024, at 9:05 a.m., with Resident 2 in Resident 2's room, Resident 2 as observed walking back and forth in the room and hallways. Resident 2 stated he remembered getting hurt but refused to talk about the altercation with Resident 1. During an interview on 9/9/2024, at 9:06 a.m. with Resident 5, Resident 5 stated all the nurses were aware of Resident 2's behavior of yelling and screaming in his room and hallways. During a concurrent observation and interview on 9/9/2024, at 9:35 a.m. with Resident 1 in Resident 1's room, Resident 1 stated he could not remember what happened on 8/31/2024. Then Resident 1 got up from his bed and stepped out of the room in a hurry. During a telephone interview on 9/9/2024, at 10:32 a.m. CNA 1 stated she was in the hallway when she saw Resident 1 sitting in a wheelchair. Resident 1 got up to ask for coffee, and in his absence, Resident 2 sat on Resident 1's wheelchair. When Resident 1 returned, he found Resident 2 occupying his wheelchair, which led to an argument between them. CNA 1 stated she intervened, instructing Resident 2 to get out of the wheelchair. CNA 1 stated when she observed Resident 1 throw a coffee cup at Resident 2, she yelled at Resident 1 to stop. CNA 1 stated that she did not separate the two residents during their argument because she felt scared, particularly given Resident 1's physical stature and his tendency to become unexpectedly aggressive. CNA 1 stated Resident 1 and Resident 2 were ignoring her and continued to argue. CNA 1 stated she tried to seek help, but no one was available at that moment. CNA 1 stated eventually, Licensed Vocational Nurse (LVN 1) intervened and separated the two residents. CNA 1 stated Resident 2 liked to pace around the facility, often asking for food and occasionally talking to himself or using profanity. CNA 1 stated Resident 1 could become aggressive if someone challenged him. CNA 1 stated she should have intervened earlier to separate Resident 1 and Resident 2 during their argument about the wheelchair to prevent the situation from escalating to the point where Resident 1 threw the coffee cup towards Resident 2. During a telephone interview on 9/9/2024, at 12:32 p.m. LVN 1 stated she separated Resident 1 and Resident 2 on 8/31/2024. LVN 1 stated Resident 2's head was hurting and was bleeding on the right side of the head after the altercation with Resident 1. LVN 1 stated residents (in general) should be separated right away to prevent altercation and harm. 2. A review of Resident 3's Admission Record indicated Resident 3, a 32-year-old female, initially was admitted to the facility on 6/19/2024 and readmitted on 8/29/2024 with diagnoses including paranoid schizophrenia (mental illness characterized by a pattern of behavior where a person feels distrustful and suspicious of other people and surroundings) and major depressive disorder ( mental health disorder characterized by persistently depressed mood or loss of interest in activities causing impairment in daily life). A review of Resident 3's H&P dated 7/2/2024, indicated Resident 3 was able to make decisions for activities of daily living ([ADL] basic self-care tasks that people perform every day). A review of Resident 3's MDS dated 9/2/2024, indicated Resident 3 had severe cognitive impairment and was independent with eating, and bed mobility. A review of Resident 3's Care Plan titled, "Physical altercation with other resident initiated 9/6/2024, the s goals for Resident 3 included for the resident be able to express emotions of physical altercation. The Care Plan's interventions included encouraging alternate dispute resolution (process to resolve disagreement) by talking versus violence, providing safe and hazard-free environment to the resident and transfer to general acute hospital (GACH) for psychiatric evaluation (relating to mental illness and treatment). A review of Resident 3's Care Plan titled, "Physical aggression manifested by inappropriately touching female staff related to poor impulse control," the goal for the resident was not to harm self or others and to seek out staff when agitation occurred. The Care Plan's interventions included analyzing times of day, places, circumstances, triggers, and what deescalates (reduce intensity) behavior and document. A review of Resident 4's Admission Record indicated Resident 4, a 41-year-old female, was admitted to the facility on 8/1/2024 with diagnoses including paranoid schizophrenia, generalized anxiety disorder and seizure (sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and level of consciousness). A review of Resident 4's H&P dated 8/3/2024, indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4's MDS dated 8/8/2024, indicated Resident 4 was independent with bed mobility, chair/bed-to-chair transfer, sitting and standing. A review of Resident 4's COC Evaluation dated 9/6/2024 timed at 5:30 p.m., the COC indicated the Registered Nurse Supervisor (RNS) observed a staff member at the hallway yelling "stop." The COC indicated Resident 3, who was hallucinating (experiencing a sensory perception that is not real) hit Resident 4 on the face. A review of Resident 4's Care Plan titled, "Allegation of physical altercation with other resident" initiated on 9/6/2024, the goal for Resident 4 was not to have further episodes of physical altercation. The Care Plan's interventions included providing safe, hazard free environment and transfer to GACH for further evaluation and treatment. During an observation on 9/9/2024, at 4:08 p.m. in Resident 4's room, Resident 4 was lying in bed, wearing a soft helmet with periorbital redness or discoloration on her right eye. Resident 4 got up immediately when asked questions regarding the altercation and was observed having involuntary movements of both arms and hands while walking out of her room. During a telephone interview on 9/10/2024, at 4:44 p.m. CNA 2 stated Resident 3 punched Resident 4 on the face while walking towards Resident 4. CNA 2 stated he ran towards Resident 4 as soon as she (Resident 4) fell down the floor together with other staff members. CNA 2 stated Resident 4 did not do anything to Resident 3 to provoke the incident or make Resident 3 angry. During an interview on 9/9/2024, at 3:33 p.m. CNA 6 stated he was assigned to Resident 4 on that day but did not know what happened between Resident 3 and Resident 4's altercation because he was in another resident's room. CNA 6 stated Resident 4 had redness on her right eye and ice pack was applied. CNA 6 stated he monitored Resident 4 and instructed her not to get near Resident 3. CNA 6 stated Resident 4 looked afraid and scared after the incident and stayed in her room. During an interview on 9/10/2024, at 8:38 a.m. the Director of Staff Development (DSD) stated Resident 3 does not like getting physically close to anyone and on 9/6/2024, Resident 4 came close to Resident 3 when they crossed paths in the hallway. The DSD stated she was in her office but was doing something else and was not really looking at both residents when it happened. During a telephone interview on 9/10/2024, at 2:27 p.m. the Registered Nurse Supervisor (RNS1) stated he was at the desk in the Nursing Station when the incident happened on 9/6/2024 and rushed to the scene. RNS 1 stated the DSD and CNA 2 separated Resident 3 and Resident 4. RNS 1 stated Resident 3 had paranoid schizophrenia and Resident 4 had some tics (compulsive, repetitive movement that's often difficult to control) or movements in her hands and arms which probably made Resident 3 thought she was getting attacked by Resident 4 and this led to Resident 3 hitting Resident 4. RNS 1 stated when he talked to Resident 3, the resident told him that Resident 4 was touching her. RNS 1 stated monitoring of residents with behavioral problems, decluttering the hallway, reporting of any change of behavior, anticipating residents' needs, and placing a CNA in the hallway will help ensure safety and prevention of injury of residents. During an interview on 9/10/2024, at 4:00 p.m. the Director of Nursing (DON) stated the facility needed to monitor residents' behavior properly to prevent injury or altercation. The DON stated the staff should have intervened and separated Resident 1 and Resident 2 when the residents were arguing over the wheelchair. A review of facility's policy and procedure (P&P) titled, "Abuse-Prevention, Screening, & Training Program" revised 7/2018, indicated the facility conducts resident pre-admission, admission and ongoing assessments and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The P&P indicated the facility ma