Other·April 17, 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. §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - § 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 2/20/2024 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 2 chased Resident 1 and kicked Resident 1 in the face when he fell while running away from Resident 2 and hit the Registered Nurse Supervisor in the face on 2/17/2024. On 2/27/2024, CDPH conducted an unannounced visit to the facility to investigate the FRI allegations. Upon investigation, CDPH determined the facility did not protect Resident 1 from Resident 2's physical abuse. Resident 2 chased Resident 1 and kicked Resident 1 in the face when Resident 1 fell while was running away from Resident 2. Resident 1 sustained a nasal bone fracture (broken nose). The facility failed to: 1. Ensure Resident 2, who had a history of physically aggressive behavior towards residents, did not physically abuse Resident 1 and facility staff. 2. Ensure Resident 2 was assessed and supervised for aggressive behavior toward the residents and to prevent Resident 2 from physically attacking Resident 1 on 2/17/2024. 3. Inform Resident 2's psychiatrist (a specialist who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) and/or primary physician of Resident 2's increased agitation, threatening behavior, spitting on staff on 2/8/2024, refusing care, and refusing medications. As a result, Resident 2 chased Resident 1 and kicked Resident 1 in the face when Resident 1 fell while running away from Resident 2 on 2/17/2024. Resident 1 sustained a nasal bone fracture. A review of Resident 1's Admission Record, indicated Resident 1 a 59-year-old male, was admitted to the facility on 8/31/22, with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/8/23, indicated Resident 1 had moderate impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 1 was independent for toileting, personal hygiene, and supervision with upper and lower body dressing. A review of Resident 1 ' s Facial Bones Xray (digital image of the facial bones) dated 2/17/24, indicated Resident 1 had a nasal bone fracture. A review of Resident 2 ' s Admission Record, indicated Resident 2 a 70-year-old male, was admitted to the facility on 9/11/2018, with diagnoses including paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder (mental illness causing persistent fear and/or worry) and hypertension (high blood pressure). A review of Resident 2 ' s MDS, dated 12/12/23, indicated, Resident 2 was independent for toileting, showering, personal hygiene, and did not utilize a wheelchair or scooter for mobility. A review of Resident 2 ' s Annual Psychiatric Evaluation Progress Notes, dated 9/16/23, indicated Resident 2 was seen for annual psychiatric evaluation (assessment of a resident ' s mental health). The Annual Psychiatric Evaluation Progress Notes indicated Resident 2 had a long history of paranoid schizophrenia on admission on 9/11/2018 with history of (h/o) aggressive behavior, h/o being on 5150 (allows an adult who was experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) hold for danger to others, h/o attempted use of a weapon on unknown staff, h/o an increased paranoid delusion (reflect profound fear and anxiety along with the loss of the ability to tell what's real and what's not real) due to being noncompliant with medication. A review of Resident 2 ' s Medication Administration Record (MAR) dated 2/2024, indicated a physician's order dated 2/3/24 and timed at 4:30 p.m., to start Resident 2 on the following medications: 1. Ativan (used to treat anxiety) 1 milligram ([mg]- a unit of measurement) intramuscularly ([IM]-injection into the muscle) every 6 hours as needed for increased agitation and delusions for 14 days, administer with Haldol (medication used to treat mental disorders) 10 mg IM and Benadryl (used in mental health as a sedative [induce sleep] and hypnotic {sleep inducing drug}) 50 mg IM. A review of Resident 2's Social Service Progress Note dated 2/5/24, indicated, Resident 2 was encouraged to take his medications and respect the boundaries of others. The Social Service Progress Notes indicated Resident 2 was following the laboratory technician around the building and would not stop even after laboratory technician asked Resident 2 to stop. The Social Worker (SW) attempted to ask Resident 2 about the incident with the laboratory technician, but Resident 2 became extremely agitated, stood in front of the SW yelling, cursing, and threatening to kill SW. The Social Service Progress Notes indicated SW informed the staff of Resident 2 ' s aggressive behavior and threats. The Social Service Progress Notes indicated she (SW) will inform Resident 2's nurse practitioner (a nurse with advances clinical education and training) regarding Resident 2 ' s aggressive behavior and refusal to take his medication. A review of Resident 2 ' s Care Plan titled "The resident has the potential to be physically aggressive and at risk for altercations with other(s) due to anger, poor impulse control (difficulty some people have in stopping themselves from engaging in certain behaviors)" dated 2/5/24, indicated the care plan interventions included the following when Resident 2 becomes agitated: 1. Intervene before agitation escalates. 2. Guide away from source of distress. 3. Engage calmly in conversation, and if response was aggressive, staff to walk calmly away, and approach later. A review of Resident 2 ' s Psychiatric Progress Notes dated 2/6/24, indicated Resident 2 reported to have been refusing his oral medications, becoming more bizarre, delusional (profound fear and anxiety along with the loss of the ability to tell what was real and what was not real) and as needed medication had to be given to Resident 2 due to being non-compliant, resisting care/laboratory tests. The Psychiatric Progress Notes indicated Resident 2 verbalized "Once in a while I stop taking meds because I want them flush out of my system." The Psychiatric Progress Notes indicated psychiatrist (a medical doctor who diagnoses and treats mental, emotional, and behavioral disorders) spoke with Resident 2 ' s family member (FM) on the phone, and FM stated Resident 2 ' s behavior gets worse when he stops taking his medications. A review of Resident 2 ' s Nursing Progress Notes dated 2/8/24 and timed at 6:57 a.m., indicated Resident 2 was offered his morning medication but Resident 2 spit at staff, took the medication cup and threw it on the floor. When licensed staff informed Resident 2 of needing to administer his Haldol IM, Resident 2 with increased agitation run away from the licensed staff to the patio. The Nursing Progress Notes indicated Resident 2 was threatening, spitting at staff, running, and trying to climb the patio[GA1][AC2][AC3] fence. Staff was able to give the medication to Resident 2. The Nursing Progress Notes indicated that after administration of IM medication Resident 2 spit on the Assistant Director of Nursing (ADON) then pushed Mental Health Worker (MHW) to the ground and kicked him. Resident 2 then sat in the garden patio and was monitored every 15 minutes by staff. Resident 2 refused to have vital signs ([V/S] clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). During an interview on 2/28/24 at 11:00 a.m., the Registered Nurse Supervisor (RNS 1) stated that on 2/17/2024 she was walking towards Station 1 when she saw Resident 1 running while Resident 2 was chasing him. RNS 1 stated, she yelled stop and called Code Green (informs the team that an agitated individual needs help de-escalating). RNS 1 stated Resident 1 fell on the ground and Resident 2 kicked Resident 1 in the face. Resident 2 then hit RNS 1 in her face. RNS 1 stated, she does not remember anything after Resident 2 hit her as she became dizzy and was traumatized with the incident. RNS 1 stated she had pain and swelling after the incident and was seen in the hospital and released the same night. RNS 1 stated Resident 2 was arrested (does not recall date of arrest) by the police and no longer a residing at the facility. RNS 1 stated when residents (in general) have aggressive behaviors such as cursing, yelling, throwing objects, and verbally threatening others it should be reported to the physician immediately to avoid further escalation. During an interview on 3/4/24 at 9:18 a.m. the License Vocational Nurse (LVN 1) stated when residents refuse psychiatric medication or exhibits aggressive behaviors the psychiatrist was supposed to be notified. LVN 1 stated Resident 2 normally takes his medications but on 2/17/2024 Resident 2 refused to take his medications. LVN 1 stated he did not notify Resident 2's psychiatrist because he went to lunch and when he returned from lunch the incident occurred. LVN 1 stated all staff are responsible for notifying the physician when residents refuse psychiatric medications or exhibit aggressive behaviors. LVN 1 stated it was important to notify the physician because Resident 2's medications may need to be adjusted, increased or another medication may need to be added to help with the aggressive behaviors and refusal of care. LVN 1 stated refusal of medication could lead to escalated aggression and violent behavior leading to harm to other residents and staff. A review of Resident 2's Medication Administration Record (MAR) for the month of 2/2024 indicated to monitor the resident for behavior of paranoid delusions and place a plus sign if the behavior was present. The MAR indicated Resident 2 had the behavior of paranoid delusions on 2/3/2024, 2/4/2024, and 2/5/2024. During an interview on 3/9/24 at 9:05 a.m. Certified Nurse Assistant (CNA 1) stated Resident 2 was refusing care and his medications and was verbally aggressive towards LVN's. CNA 1 stated Resident 2 was yelling a lot and being aggressive towards staff. CNA 1 stated she witnessed Resident 2 cursing and yelling on 2/8/24 and it should have been reported to the LVN or nursing supervisor. CNA 1 stated it was important to report those aggressive behaviors because the residents (in general) aggression could escalate and they could harm themselves, other residents, or staff. CNA 1 stated she did not report Resident 2's aggressive behavior at the time she observed it. During an interview on 3/11/24 at 3:50 p.m. with RNS 2, RNS 2 stated Resident 2 was not socializing with other residents. RNS 2 stated when residents (in general) have negative behavior such as cursing, yelling, and throwing objects it should be reported to the doctor immediately before the behavior escalates. RNS 2 stated Resident 2 started to become more agitated and refused to take his medications prior to 2/17/2024. RNS 2 stated when residents (in general) are on 24-hour observations every 15 minutes and a resident (in general) is observed to have an aggressive behavior, this resident should be placed on 1:1 monitoring (terms used for a registered nurse or health care support worker whose role it is to provide one to one nursing or observation care to an individual patient for a period of time), and the doctor should be notified immediately. RNS 2 stated the doctor should be notified immediately to ensure the other residents and staff remain safe. RNS 2 stated if a resident (in general) has one episode of aggressive behavior or on episode of paranoid delusions the doctor should be notified. During an interview on 3/13/24 at 9:32 a.m., the Clinical Director (CD), stated Resident 2 had no prior aggressive behavior towards other resident, and that Resident 2 only exhibited aggressive behavior toward staff when he had to take his monthly injection of Haldol because he was paranoid and believed that the staff were trying to poison him. CD stated Resident 2 was placed on 24-hour observation for danger to others on 2/5/24 because Resident 2 was aggressive toward SW and threatened to kill her when she was trying to speak to him about the incident that occurred over the weekend with the laboratory technician being followed by Resident 2 throughout the facility. CD stated when the residents (in general) exhibit negative behavior during the 24-hour observation, such as property destruction/throwing objects, the doctor should be notified because the resident might need a different level of observation such as 1:1 monitoring, a higher level of care, or as needed medication may need to be adjusted. During an interview 3/14/24 at 11:54 a.m., LVN 1 stated Resident 2 would become aggressive towards staff when it was time to administer medications. LVN 1 stated on the day of the incident (2/17/2024) Resident 2 refused his medications, which was typical, however, Resident 2 would eventually take his medications if offered again. LVN 1 stated Resident 2 continued to refuse