Health inspection·September 11, 2024

483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(a) The facility must: 42 CFR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CFR § 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. 22 CFR § 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 CFR § 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. On 7/29/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating a resident (Resident 8) twisted his leg when walking with a Certified Nursing Assistant (CNA 4). Resident 8 was put back to bed and had complaints of pain to the left hip. An X-ray revealed Resident 8 sustained a left hip fracture (broken bone). On 7/31/2024, the CDPH conducted an unannounced FRI investigation at the facility. The facility failed to: 1. Implement its policy and procedure ((P&P) titled “Abuse-Prevention, Screening, & Training Program” which indicated the facility did not condone any form of resident abuse or neglect. 2. Implement its P&P titled, “Resident Rights,” which indicated residents had the freedom of choice, about how they wish to live their lives and receive care. As a result, CNA 4 grabbed Resident 8’s left arm tightly, pulled and pushed Resident 8 to the floor, causing Resident 8 to sustain a left hip fracture (broken bone), which required admission to a General Acute Care Hospital (GACH) for evaluation and treatment. During a concurrent review of the facility’s surveillance video footage and interview on 8/1/2024 at 12:55 p.m., with the Assistant Director of Nursing (ADON), the video footage, dated 7/28/2024 and timed from 8:09 a.m. to 8:20 a.m., was reviewed. The ADON stated, the video footage indicated the following:  a. At 8:09 a.m., CNA 4 was walking behind Resident 8, CNA 4 grabbed Resident 8’s left upper arm, pulled, and pushed Resident 8 to the floor, on his left side. Resident 8 was grimacing (facial expression indicating pain) and was unable to get back up on his feet unassisted. CNA 4 grabbed Resident 8’s right arm and pulled Resident 8 up. Resident 8 stood up on his right leg but was not able to stand up on his left leg. Then CNA 4 held Resident 8’s left arm and Resident 8 held onto the hallway side rails with his right hand. Resident 8 was limping (walking with difficulty) and unable to stand on his left leg as he walked towards the nursing station. b. At 8:10 a.m., CNA 4 assisted Resident 8 onto a chair in the hallway, in front of the nurses’ station, left Resident 8 there, and walked way. c. At 8:17 a.m., CNA 4 assisted Resident 8 up from the chair by holding Resident 8’s right arm. Resident 8 was observed holding onto the side rail with his left arm, stood up from the chair and started walking while CNA 4 held him from the right side. Resident 8 had an unsteady gait, limped, and grimaced as he walked.  d. At 8:19 a.m., Resident 8 and CNA 4 walked into Resident 8’s room. e. At 8:20 a.m., CNA 4 walked out of Resident 8’s room.  Resident 8, was a 60 year-old male, admitted to the facility on 1/19/2024 with diagnoses including hypertension (high blood pressure), anxiety (feeling of fear, dread, and uneasiness), major depression (a mood disorder that affect how a person feels, thinks, and handles daily activities), dysphagia (difficulty swallowing), Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 8’s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 4/25/2024, indicated Resident 8 had the ability to express ideas and wants, and had clear comprehension (capability of understanding something). The MDS indicated Resident 8 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and personal hygiene.  A review of Resident 8’s History and Physical (H&P), dated 1/19/2024, indicated Resident 8 had the capacity to understand and make decisions.  A review of Resident 8’s Change of Condition ([COC] change of condition clinically important deviation from a resident’s baseline in physical, cognitive, behavioral, or functional status), dated 7/28/2024, indicated an unidentified CNA was walking with Resident 8 when the resident suddenly twisted his left leg. The COC indicated Resident 8 walked back to his room unassisted. The COC also indicated Resident 8’s roommate (Resident 9) reported to an unidentified Registered Nurse (RN) that Resident 8 said he broke his leg and needed help. During a telephone interview on 7/31/2024 at 4:15p.m., with Resident 8, Resident 8 stated he was admitted to the GACH on 7/28/2024 due to a left leg fracture. Resident 8 stated on the morning of 7/28/2024 (resident did not remember the time) CNA 4 pushed him to the floor and dragged him in the hallway. Resident 8 stated CNA 4 was upset because he (Resident 8) did not want his blood pressure checked. Resident 8 stated now he was unable to walk, was in pain, and required left hip surgery. Resident 8 stated he was very upset, angry, and did not feel safe to go back to the facility. A review of Resident 8’s “Witnessed Fall,” report dated 7/28/2024, indicated CNA 4 stated he was trying to take resident’s vital signs when suddenly Resident 8 slipped and fell, twisting his left leg. The report indicated CNA 4 stated Resident 8 then walked back to his room by himself, laid in bed. The report indicated CNA 4 stated Resident 8 had a pain level of 3 out of 10 (0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-9 = severe pain]) to his left leg with movement. A review of Resident 8’s Order Summary Report, dated 7/28/2024 indicated X-ray (a photographic image of a part of the body) of the left hip, left upper leg and left lower leg due to pain on left leg status post ([s/p] after) a witnessed fall. A review of Resident 8’s X-ray result dated 7/28/2024, indicated displaced left femoral neck fracture (intracapsular [within the capsule of a joint] hip fracture). A review of Resident 8’s Progress Note dated 7/28/2024 at 7:00 p.m., indicated Resident 8 was transferred to GACH for medical evaluation due to left leg and left hip pain.  A review of Resident 8’s GACH Admission Record, dated 7/28/2024, indicated Resident 8 was admitted to the GACH on 7/28/2024 with diagnosis of fracture of the left hip. A review of Resident 8’s GACH Orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) Surgical Consultation Report, dated 7/29/2024, indicated Resident 8 was pending hemiarthroplasty (a procedure used to treat hip fractures) surgery of the left hip.  A review of Resident 8’s GACH Operative Report, dated 8/2/2024, indicated on 8/2/2024, Resident 8 had a hemiarthroplasty of the left hip, related to a left femoral neck fracture.  During an interview on 8/1/2024 at 9:00 a.m., CNA 4 stated on 7/28/2024 around 9:00 a.m., he (CNA 4) was preparing to take Resident 8’s blood pressure. CNA 4 stated Resident 8 was seated in a chair in the hallway, in front of the nurses’ station. CNA 4 stated Resident 8 refused to have his blood pressure checked. CNA 4 stated Resident 8 stood up fast from the chair, twisted his leg, and lost his balance. CNA 4 stated he grabbed Resident 8’s arms and slowly assisted Resident 8 to the floor. CNA 4 stated he helped Resident 8 get up from the floor and they walked to Resident 8’s room. CNA 4 stated he assisted Resident 8 into bed, Resident 8 complained of pain, and the resident did not specify where. CNA 4 stated he left Resident 8’s room and reported Resident 8’s complaints of pain to Licensed Vocational Nurse (LVN 4).  During a telephone interview on 8/1/2024 at 11:45 a.m., LVN 4 stated on 7/28/2024 at 9:30 a.m., Resident 9 informed her that Resident 8 was in pain and needed help. LVN 4 stated she went to Resident 8’s room and observed the resident was in bed complaining of pain to his left leg and left hip. LVN 4 stated Resident 8 said he was not able to move his left leg and hip due to severe pain. LVN 4 stated Resident 8 told her while he was walking in the hallway, he twisted his left leg, fell, and broke his leg. LVN 4 stated she notified Registered Nurse (RN 8).  During an interview on 8/1/2024 at 12:10 a.m., RN 8 stated LVN 4 notified her of Resident 8’s left leg and left hip pain. RN 8 stated while she was assessing Resident 8’ s left leg and left hip, Resident 8 reported a pain level of 8/10, to the left hip and left leg. RN 8 stated she notified Resident 8’s physician (MD 1) and obtained orders for an X-ray of the left hip and left leg. RN 8 stated the X-ray results indicated Resident 8 had a displaced left femoral fracture. RN 8 stated Resident 8 was transferred to the CAGH for medical evaluation and treatment. During a telephone interview on 8/14/2024 at 1:26 p.m., with a GACH Social Worker (SW), the GACH SW stated Resident 8 had been admitted to the GACH for 17 days. The GACH SW stated Resident 8 was waiting to be discharged to another skilled nursing facility because Resident 8 did not want to go back to the same facility and requested to be discharged to a different facility. The GACH SW stated Resident 8 reported he did not feel safe to go back to the same facility.   2. Resident 9, was a 61-year-old male, who was originally admitted to the facility on 2/22/2024, and readmitted on 4/9/2024 with diagnoses which included schizophrenia, anxiety, and hypertension.  A review of Resident 9’s MDS, dated 5/30/2024, indicated Resident 9 could make his needs known, understand others and able to be understood. The MDS indicated Resident 9 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, showering, and personal hygiene.  A review of Resident 9’s H&P, dated 4/10/2024, indicated Resident 9 could make needs known but could not make medical decisions. During an interview on 8/1/2024 at 10:30 a.m., Resident 9 (Resident 8’s roommate), stated on the morning of 7/28/2024 (resident did not remember the exact time), his roommate (Resident 8) complained of pain. Resident 9 stated none of the staff came to check on Resident 8. Resident 9 stated Resident 8 said he (Resident 8) was pushed to the floor and dragged in the hallway by CNA 4, breaking his leg and hip. Resident 9 stated he went to the nursing station and reported to LVN 4 that Resident 8 was in severe pain and needed help. Resident 9 stated LVN 4 came into the room and assessed Resident 8’ s condition and pain.  A review of the facility’s P&P titled, “Resident Rights,” revised 1/1/2012, indicated the facility will promote and protect residents’ rights. The P&P indicated residents had the freedom of choice, about how they wish to live their lives and receive care. The P&P indicated employees will treat residents with kindness, respect, and dignity and honor residents’ rights. The P&P indicated the facility did not force, discriminate, or retaliate against a resident for exercising his or her rights. A review of the facility’s P&P titled “Abuse-Prevention, Screening, & Training Program,” revised 7/2018, indicated the facility did not condone any form of resident abuse, or neglect. The P&P defined abuse as the willful, deliberate infliction of injury such as verbal abuse, or physical abuse that caused physical harm, or mental anguish.  The facility failed to: 1. Implement its P&P titled “Abuse-Prevention, Screening, & Training Program” which indicated the facility did not condone any form of resident abuse or neglect. 2. Implement its P&P titled, “Resident Rights,” which indicated residents had the freedom of choice, about how they wish to live their lives and receive care. As a result, CNA 4 grabbed Resident 8’s left arm tightly, pulled and pushed Resident 8 to the floor, causing Resident 8 to sustain a left hip fracture, which required admission to a GACH for evaluation and treatment. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.