Health inspection·August 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. §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 § 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 6/25/024 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging that on 6/24/2024 Resident 1 went to Resident 2's room and hit Resident 2 in the face and that on 6/28/2024 Resident 3 hit Resident 4 in the face while she was sitting in a wheelchair in the hallway. On 7/5/2024, CDPH conducted an unannounced visit to the facility to investigate FRI allegations. Upon investigation, CDPH determined the facility did not protect Resident 1 from Resident 2's physical abuse and did not protect Resident 4 from Resident 3's physical abuse. On 6/24/2024 Resident 1 entered Resident 2's room and hit him on the face and on 6/28/2024 Resident 3 hit Resident 4 in the face while she was sitting on the wheelchair in the hallway. The facility failed to: 1. Ensure Resident 2, who was exhibiting auditory hallucination (hearing voices or noises that are not there), paranoid delusion (a type of serious mental illness where patient cannot tell what is real from what is imagined), and visual hallucination (perception of an external visual stimulus where none exists) did not physically abuse Resident 1. 2. Ensure Resident 3, who was exhibiting behaviors such as agitation (manifested by striking out), anxiety (persistent and excessive worry) and mood swings (extreme of sudden change of mood) did not physically abuse Resident 4. 3. Ensure the licensed nurses followed the facility's policy and procedure (P&P) titled, "Notification of Physician/Prescriber," to inform Resident 1's physician of changes in the resident's behavior manifested by increased number of auditory hallucination and paranoid delusion in June 2024 leading to Resident 1 hitting Resident 2 in the face. 4. Ensure the licensed nurses followed the facility's P&P titled, "Notification of Physician/Prescriber," to inform Resident 3's physician of changes in the resident's behavior in June 2024, manifested by agitation, anxiety, and mood swings leading to Resident 3 with a closed fist hitting Resident 4 in the forehead area. These deficient practices resulted in: 1. Resident 1 was hallucinating of being raped by Resident 2, and on 6/24/2024 went to Resident 2's room and hit him in the face. 2. On 6/28/2024 Resident 3 hit Resident 4 in the face while Resident 4 was sitting in a wheelchair in the hallway. 1. A review of Resident 1 ' s Admission Record, indicated Resident 1, a 55-year-old male, was admitted to the facility on 6/20/2023, with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 3/28/2024, indicated, Resident 1 had intact (not affected) cognitive skills for daily decision making. The MDS indicated Resident 1 had delusions (misconception or beliefs that are firmly held, contrary to reality). Resident 1 was independent for toileting, personal hygiene, and required supervision with upper and lower body dressing. A review of Resident 1 ' s Psychiatric Progress Notes dated 6/25/2024, indicated, on 6/24/2024 during nighttime, Resident 1 went to Resident 2's room and started hit Resident 2 in the face. The Psychiatric Progress Notes indicated Resident 1 reported he had a dream about being raped by Resident 2. The Psychiatric Progress Notes indicated Resident 1 has "No understanding to his condition, poor coping skills, appears to have preoccupied aggressive content with command hallucinations, unwilling to have meaningful conversation." The Psychiatric Progress Notes indicated Resident 1 was placed on 1:1 monitoring (health care staff whose role was to provide one to one observation to an individual patient for a period of time) for safety precautions. A review of Resident 1's Nursing Progress Notes dated 6/24/2024 timed at 8:30 p.m., indicated, staff heard a commotion coming from Resident 2's room. The Nursing Progress Notes indicated staff heard Resident 2's saying, "He is hitting me." The Nursing Progress Notes indicated staff saw Resident 1 leaving Resident 2's room. The Nursing Progress Notes indicated Resident 1 was interviewed and stated he had a dream Resident 2 raped him. The Nursing Progress Notes indicated Resident 1's physician was informed and ordered Ativan one milligram (mg) every eight hours only when necessary (prn), Haldol 10 mg with Benadryl 50 mg, not to exceed three doses in 24 hours, and to place Resident 1 on 1:1 monitoring due to assaultive behavior. A review of Resident 1's Physician's Order Summary Report dated 5/23/2024, indicated a physician's order to "Monitor the resident for behavior including auditory hallucination, labile mood, paranoid delusion, visual hallucination. Place a positive (+) sign if behavior is present or a (-) if the behavior is absent." A review of Resident 1's Medication Administration (MAR) for the month of 6/2024, indicated a positive (+) sign for auditory hallucination on 6/10/2024, 6/11/2024, 6/12/2024, 6/13/2024, 6/19/2023, 6/20/2024, and 6/21/2024. The MAR indicated a positive (+) sign for paranoid delusion on 6/12/2024, 6/13/2024, 6/16/2024, 6/19/2024, 6/20/2024, and 6/21/2024 and visual hallucination 6/10/2024, 6/11/2024, 6/12/2024, 6/16/2024, 6/19/2023, and 6/20/2024. A review of Resident 1s Psychiatric Progress Notes dated 7/2/2024, indicated, Resident 1 was seen for annual psychiatric evaluation (assessment of a resident's mental health). The Psychiatric Progress Notes indicated Resident 1 continued to have delusional beliefs about the altercation incident with Resident 2. The Psychiatric Progress Notes indicated Resident 1 kept saying he was molested (sexual assault or abuse) by Resident 2 who came to him multiple times, when in fact Resident 1 had no contact with Resident 2. A review of Resident 2 ' s Admission Record, indicated Resident 2, a 72-year-old male, was admitted to the facility on 6/7/2024, with diagnoses including schizoaffective disorder (a serious mental illness that affects how a person thinks, feels, and behaves), and type 2 diabetes mellitus ((a condition in which the body fails to metabolize (process) glucose (sugar) correctly). A review of Resident 2's Nursing Progress Notes dated 6/24/2024 at 8:20 p.m., indicated Certified Nursing Assistant (CNA) heard a commotion in Resident 2's room. CNA went to the room and heard Resident 2 saying "He hit me." The Nursing Progress Notes indicated Resident 2 was assessed and observed to have a left cheek swelling. A review of Resident 2's Nursing Progress Notes dated 6/25/2024 at 1:09 p.m. indicated to "continue to monitor Resident 2 for safety related to being hit by Resident 1 in the face, sustained left face swelling." During an interview on 7/5/2024 at 11:07 p.m. inside Resident 2's room, Resident 2 stated Resident 1 walked into his room and started to hit him in his face. Resident 2 stated he was not doing anything, and Resident 1 hit him in his face. Resident 2 stated he had a headache afterward, but it went away. During an interview on 7/5/2024 at 11:15 a.m., Resident 1, stated he was raped by a "guy that is why I beat him up." During a concurrent interview and Resident 1's MAR review on 7/8/024 at 10:28 a.m., with the Director of Nursing (DON), the DON stated Resident 1 went to Resident 2's room (opposite to his room) and hit Resident 2 in a left side of his face and accused him of raping him (Resident 1). Resident 1's MAR indicated Resident 1 have been exhibiting behaviors auditory hallucination, paranoid delusion, and visual hallucinations. The DON stated the facility did not do anything to control Resident 1's behavior until it escalated when Resident 1 hit Resident 2 in the face. The DON stated if staff sees resident (in general) to be more aggressive or delusional more than usual, staff should inform resident's physician. The DON stated it was important to inform resident physician with any change in behavior. 2. A review of Resident 3 ' s Admission Record, indicated Resident 3, a 68-year-old, male admitted to the facility on 2/27/2020, with diagnosis including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 3 ' s MDS, dated 6/21/2024 indicated, Resident 3 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 3 had delusions. The MDS indicated Resident 3 required moderate assistance for toileting, personal hygiene, and upper and lower body dressing. A review of Resident 3's Physician's Order Summary Report dated 5/23/2024, indicated to "Monitor for behavior: agitation manifested by striking out, anxiety, mood swings, and paranoid delusions. Place a positive (+) sign if behavior was present or a (-) if the behavior was absent. A review of Resident 3's MAR for the month of 6/2024, the MAR indicated a positive (+) sign for agitation ,anxiety, and mood swings on 6/28/2024 (7 a.m. -3 p.m., 3 p.m.-11 p.m. and 11p.m. -7 a.m. shift). A review of Resident 3's Nursing Progress Notes dated 6/28/2024 at 3:32 p.m., indicated Resident 4 hit Resident 3 multiple times. Resident 4 had shown symptoms of increased agitation. A review of Resident 4's Admission Record, indicated Resident 4, a 66-year-old, female admitted to the facility on 10/19/2018, with diagnoses including schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly) and anxiety disorder. A review of Resident 4 ' s MDS dated 4/19/2024, indicated, Resident 4 had moderate impairment in cognitive skills for daily decision making. The MDS indicated Resident 4 had delusions and was independent for toileting, personal hygiene, and upper body dressing. A review of Resident 4's Nursing Progress Notes dated 6/28/2024 at 12:30 p.m., indicated at 11:40 a.m., Resident 4 was sitting in her wheelchair against the wall in a hallway when Resident 3 was observed hitting her in the forehead area with a closed fist, while Resident 4 was covering her face. The Director of Rehabilitation (DOR) intervene and wheeled Resident 4 away from Resident 3. The progress notes indicated Resident 4 had no injury. During an interview on 7/8/2024 at 12:40 p.m., the DOR, stated she was walking down the hallway on 6/28/2024 when she noticed Resident 3 hitting Resident 4. The DOR stated Resident 4 was covering her face while Resident 3 was hitting her with a closed fist. The DOR stated there was nobody around and Resident 4 could not scream loud. The DOR stated she did not know how long Resident 3 was hitting Resident 4. The DOR stated the incident happened before lunch on 6/28/2024. The DOR stated Resident 3 gets agitated easily with no apparent reason and Resident 4 was very quiet. A review of the facility's P&P titled "Abuse Prevention and Reporting", dated 1/30/2024, the P&P indicated " the facility is committed to protecting the physical and emotional wellbeing and personal possession of every resident. Any form of mistreatment of residents including but not limited to abuse, neglect, exploitation...are strictly prohibited." A review of the facility's P&P titled, "Notification of Physician/Prescriber," dated 2023, the P&P indicated, "...the licensed nurse is responsible to inform the physician or other prescriber responsible for the medical or psychiatric care of the person served of any changes in the person served ' s emotional, behavioral, physical condition, and/or involvement in adverse events." The facility failed to: 1. Ensure Resident 2, who was exhibiting auditory hallucination, paranoid delusion, and visual hallucination did not physically abuse Resident 1. 2. Ensure Resident 3, who was exhibiting behaviors such as agitation, anxiety and mood swings did not physically abuse Resident 4. 3. Ensure the licensed nurses followed the facility's P&P titled, "Notification of Physician/Prescriber," to inform Resident 1's physician of changes in the resident's behavior manifested by increased number of auditory hallucination and paranoid delusion in June 2024 leading to Resident 1 hitting Resident 2 in the face. 4. Ensure the licensed nurses followed the facility's P&P titled, "Notification of Physician/Prescriber," to inform Resident 3's physician of changes in the resident's behavior in June 2024, manifested by agitation, anxiety, and mood swings leading to Resident 3 with a closed fist hitting Resident 4 in the forehead area. These deficient practices resulted in: 1. Resident 1 was hallucinating of being raped by Resident 2, and on 6/24/2024 went to Resident 2's room and hit him in the face. 2. On 6/28/2024 Resident 3 hit Resident 4 in the face while Resident 4 was sitting in a wheelchair in the hallway. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 3.