Health inspection·November 27, 2024

Amended: 11/29/2024 CFR § 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. CFR § 483.40 Behavioral Health Services (b) Based on the comprehensive assessment of a resident, the facility must ensure that— (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. CCR § 72301 Required Services (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. CCR § 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. 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. CCR § 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 10/9/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging a resident (Resident 1) engaged in nonconsensual sexual contact with another resident (Resident 2). On 10/9/2024 at 12:27 p.m., CDPH conducted an unannounced visit to the facility to investigate the facility-reported incident. The facility failed to: 1. Diagnose and provide Resident 1 with appropriate behavioral health services including but not limited to treating Resident 1’s history of impulsive, aggressive, and hypersexual behavior. 2. Develop and implement a plan of care for Resident 1 including but not limited to treating Resident 1’s history of impulsive, aggressive, and hypersexual behavior. 3. Keep Resident 2 free from sexual abuse through appropriate behavioral health treatment and separation from Resident 1 due to Resident 1’s history of impulsive, aggressive, and hypersexual behavior. 4. Follow the facility's (SNF B, where the resident resides) procedure and policy (P/P) titled, "Residents Rights", including Resident 2’s right to a dignified existence, to be treated with respect, kindness, and dignity, and to be free from abuse and exploitation. 5. Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 followed the facility’s (SNF B) P/P titled, "Abuse Reporting and investigation", dated 1/10/2024, which indicated "if the suspected perpetrator is the resident, the residents will be separated so they do not interact with each other or with another resident." This deficient practice resulted in Resident 1 not receiving any treatment or medications for his diagnosis of schizophrenia and history of aggression, since 8/31/2024 (admission to SNF B) leading to Resident 1 sexually assaulting Resident 2, who was his roommate, twice in one day on 10/8/2024. Resident 2 was psychosocially harmed due to Resident 1’s sexual aggression towards him. Resident 1’s sexually aggressive behavior placed other residents in the facility (SNF B) at risk for his sexual assault and aggressive behaviors. A review of Resident 1's Admission Record, indicated Resident 1, a 67-year-old male, was admitted to SNF B on 8/31/2024 with diagnoses including schizophrenia, malignant neuroleptic syndrome (life-threatening condition that can occur as a side effect of certain antipsychotic [a medication used to treat symptoms of psychosis [collection of symptoms that cause a person to lose touch with reality] medications) and diabetes mellitus type 2 (a condition when the body cannot regulate blood sugar). A review of Resident 1's History and Physical (H&P), dated 9/3/2024, indicated Resident 1 did not have awareness of place, location, and time. A review of Resident 1’s Minimum Data Set (MDS a resident assessment tool) dated 9/7/2024, indicated Resident 1 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 1 did not have any limitation in functional range of motion (range of motion required for a person to be as independent as possible). A review of Resident 1’s General Acute Care Hospital (GACH 1) records, dated 7/19/2024 through 8/31/2024, indicated on 7/19/2024 Resident 1 was admitted to GACH from SNF A on 7/19/2024. The GACH 1 records indicated Resident 1 was discharged from GACH 1 on 8/31/2024 and transferred to SNF B on 8/31/2024. A review of Resident 1’s physician’s orders from SNF A, dated 3/7/2024, indicated the following orders: 1. Clozapine 200 mg tablet by mouth at bedtime for disorganized thoughts and aggressive behaviors. 2. Clozapine 150 mg tablet by mouth in the morning for disorganized thoughts. 3. Depakote (medication to treat mood disorders) 150 mg tablet by mouth two times a day for mood swings. The physician’s orders indicated Resident 1’s medication orders were active until his transfer to GACH 1 on 7/19/2024. A review of Resident 1's Change of Condition document ([COC] significant change in resident’s status that requires intervention) form dated 10/8/2024 from SNF B, indicated Resident 1 had ‘inappropriately touched’ Resident 2. A review of Resident 1's physician’s orders, dated 10/9/2024, indicated to transfer Resident 1 to GACH 3 for psychiatric evaluation. A review of Resident 1's Nurses Progress Notes, dated 10/9/2024, indicated Resident 1 was transferred to GACH 3 on 10/9/2024 at 7:50 a.m., for psychiatric evaluation due to inappropriately touching another resident (Resident 2). A review of Resident 2's Admission Record, indicated Resident 2, a 76-year-old male, was admitted to the facility on 7/23/2024 with diagnoses including metabolic encephalopathy (disease affecting how a brain works), muscle weakness and adult failure to thrive (a state of decline caused by chronic diseases and functional impairments, manifestations of this condition include weight loss. A review of Resident 2's H&P, dated 7/24/2024, indicated Resident 2 had a decreased mental status. A review of Resident 2's MDS, dated 7/30/2024, indicated Resident 2 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 2 had limitations in functional range of motion affecting his bilateral (both) upper and lower extremities. The MDS indicated Resident 2 was dependent (helper does all the effort, resident does none of the effort to complete activity) on staff for eating, hygiene, showering/bathing, dressing, toilet hygiene (ability to maintain perineal [clean self after toileting] hygiene, adjust clothes before or after voiding, or having bowel movement). The MDS indicated Resident 2 was always incontinent of bowel and bladder (ability to maintain control of when to urinate or have a bowel movement). The MDS indicated Resident 2 was dependent on staff to roll left to right while in bed. A review of Resident 2's COC form dated 10/8/2024, indicated Resident 1 was found in Resident 2’s bed touching Resident 2 inappropriately. A review of CNA 1’s documented witness statement, dated 10/8/2024, indicated the following: on 10/8/2024 at 6:30 p.m., CNA 1 entered Resident 1 and Resident 2’s room and noticed the privacy curtain was pulled around Resident 2’s bed. Behind the curtains CNA 1 observed Resident 1 and Resident 2 laying together on their left side facing away from the door. CNA 1’s documented witness statement indicated Resident 1 and Resident 2 were naked from the waist down. Resident 1 was observed to be grinding his hips and rubbing his penis on the buttocks of Resident 2. Resident 1 had his right hand on Resident 2’s right hip moving Resident 2 back and forth while he was grinding on Resident 2. CNA 1’s documented witness statement indicated CNA 1 shouted, “hey that’s not okay and you can’t do that!”. Resident 1 stated, “ok, sorry!” got up, pulled down his gown and went back to sit on his own bed. CNA 1 called CNA 2 to the room and informed CNA 2 of the incident, and both left Resident 1 and Resident 2 in their room to report the incident to Licensed Vocational Nurse (LVN 2). During an interview on 10/9/2024, at 12:33 p.m., CNA 4 stated Resident 2 required total assistance from staff while receiving a shower. CNA 4 stated since the incident on 10/8/2024, Resident 2 has been covering his private area with his hands during showers. CNA 4 stated this is a new behavior for Resident 2. During an interview on 10/11/2024, at 1:40 p.m., CNA 1 stated her documented witness statement was an accurate account of the incident on 10/8/2024 involving Resident 1 and Resident 2. CNA 1 stated she left Resident 1 and Resident 2 in the room unattended while she went to notify LVN 2 of the incident. CNA 1 stated, it was important to separate residents after an incident of alleged abuse to ensure residents' safety. CNA 1 stated Residents 1 and 2 should have been monitored with 1:1 supervision (a single staff member is dedicated to constantly monitor one resident) to ensure the incident did not happen again. A review of CNA 2’s documented witness statement, dated 10/8/2024, indicated CNA 1 notified CNA 2 that she (CNA 1) witnessed Resident 1 grinding on Resident 2, while in Resident 2’s bed. CNA 2’s witness statement indicated CNA 2 stated she walked with CNA 1 (to go inform LVN 2 of the incident), then stopped (on the way) to inform CNA 3 of the situation. CNA 2 stated she and CNA 3 returned (from the hallway) to Resident 1 and Resident 2’s room and heard someone yelling, “help me, help me” repeatedly. CNA 2 stated she witnessed Resident 1 sitting on Resident 2’s bed, rubbing Resident 2’s leg. A review of CNA 3’s documented witness statement, dated 10/8/2024, indicated when CNA 2 and CNA 3 came to Resident 1 and Resident 2’s room they heard someone yelling, “help me, help me”. CNA 3’s witness statement indicated she observed Resident 1 sitting on Resident 2’s bed and rubbing Resident 2’s leg up and down. Resident 2 did not have his adult briefs (a disposable undergarment designed to provide absorbency for people that cannot control their bladder and/or bowel movements) on. CNA 3’s witness statement indicated Resident 1 got up and walked back to his bed. CNA 3’s witness statement indicated CNA 3 asked Resident 2 if he was okay, Resident 2 responded, “No.” CNA 3’s statement indicated Resident 2 reported to her that Resident 1 touched his penis. A review of Resident 2's Physician’s Orders, dated 10/9/2024, indicated to transfer Resident 2 to GACH 2 for further evaluation and treatment. A review of Resident 2's Nurses Progress Notes, dated 10/9/2024, indicated Resident 2 was transferred to GACH 2 on 10/9/2024 at 12:20 a.m., for further evaluation and treatment due to being touched inappropriately by another resident. During an interview on 10/11/2024, at 1:00 p.m., the Director of Nursing (DON-P) from SNF A stated Resident 1 had been a resident of SNF A since 2019 until he was transferred to GACH 1 in July 2024. DON-P stated Resident 1 was transferred to GACH 1 because he required a higher level of health care. DON-P stated, Resident 1 was receiving Clozapine and Depakote daily at their facility (SNF A) due to paranoid delusions and poor impulse control. DON-P stated when a medication dose reduction was attempted (date unknown), Resident 1 required close monitoring due to increased hypersexual behavior. DON-P stated, Resident 1 could not be without his antipsychotic medications as he would attempt inappropriate sexual behaviors and aggression towards vulnerable, dependent residents. During an interview on 10/11/2024, at 2:18 p.m., SNF B’s pharmacist (PharmD) stated upon review of Resident 1’s medication regimen on 9/6/2024, Resident 1 was noted to have a diagnosis of schizophrenia and the SNF B physician had not prescribed antipsychotic medication for Resident 1. PharmD stated if a resident was receiving an antipsychotic medication prior to admission to the current facility (SNF B), it was important for the nursing staff to inquire why Resident 1 did not continue to have a prescription for antipsychotic medications, since the resident had a diagnosis of schizophrenia and history of sexual behaviors and aggression toward other residents. During an interview on 10/11/2024 at 2:25 p.m., PharmD stated she was not aware Resident 1 was previously a resident at SNF A and was receiving antipsychotic medications. PharmD stated Clozapine is an antipsychotic medicine used to treat schizophrenia after other treatments have failed. PharmD stated the nursing staff should have notified Resident 1’s medical doctor (MD) and provided the information pertaining to Resident 1’s previous Clozapine orders and psychiatric history. PharmD stated the MD could then determine if psychiatric follow up is necessary for Resident 1, which it likely would be. During an interview on 10/11/2024, at 3:12 p.m., the DON stated when a resident is newly admitted to the facility, she reviews all the documents from the discharging facility with the MDS Nurse, the Infection Preventionist nurse, the Assistant Director of Nursing, and the Medical Records Director to ensure all orders and medications were carried out. The DON stated she overlooked the information in Resident 1’s hospital records that indicated Resident 1 was previously a resident at a psychiatric skilled nursing facility, SNF A. The DON stated she failed to note that Resident 1 was receiving Clozapine. During an interview on 10/11/2024, at 3:20 p.m., the DON stated had she taken note of Resident 1’s history, she would have reached out to DON-P and likely would not have admitted Resident 1 to the facility (SNF B). The DON stated she should have called Resident 1’s physician to notify him about Resident 1’s psychiatric history to ensure Resident 1 received the necessary assessment, treatments, and services to meet his behavioral needs. The DON stated, Resident 1 did not receive the appropriate behavior care and services due to, “our failure of looking over his psychiatric history”. The DON stated Resident 1’s impulsive behaviors were not managed appropriately which resulted in Resident 1 sexually assaulting Resident 2. The DON stated they (SNF B) failed to maintain Resident 2's safety from Resident 1 when SNF B staff left Resident 1 and Resident 2 unattended and unsupervised after CNA 1 witnessed the first inappropriate sexual act performed by Resident 1 toward Resident 2. A review of SNF B’s Facility Assessment (foundation for the facility to assess its resident population and determine the direct care staffing and other resources to provide the required care to their residents) updated 6/19/2024, indicated the following: Residents will be admitted to this facility if their nursing and medical needs can be met by the facility. The DON or designee reviews perspective inquiry documentation to determine if the facility can meet the needs and the care perspective of the residents. Residents who are admitted to the facility will have an admission assessment and a patient centered care plan developed. When a resident has been admitted to the facility and who’s care needs cannot be met, the resident’s physician will be