Health inspection·September 12, 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 7/18/2024 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging that on 7/17/2024 Resident 1 sustained a cut to his finger after Resident 2 stabbed him with a pen. On 8/1/2024, 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. On 7/17/2024 Resident 2 stabbed Resident 1 on his right index finger repeatedly with a pen. The facility failed to: 1. Ensure sharp objects including pointed pen and pencils that could potentially use to harm another resident were removed from residents’ belongings. As a result, Resident 2 stabbed Resident 1 on his right index finger repeatedly with a pen. Resident 1 sustained one inch long cut on the right index finger. A review of Resident 1’s Admission Record (Face Sheet) indicated Resident 1, a 62-year male, was admitted to the facility on 7/2/2024, with diagnoses including schizophrenia (a mental condition characterized by abnormal thought processes and unstable mood), anxiety (emotion characterized by feelings of tension, worried thoughts) and hypertension (high blood pressure). A review of Resident 1’s History and Physical (H&P) dated 7/2/2024 indicated Resident 1 was alert and oriented to name only. A review of Resident 1’s Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 7/10/2024, the MDS indicated Resident 1 did not require assistance from staff with toileting, dressing, putting on and taking off footwear, repositioning, sitting, standing, and walking. The MDS indicated Resident 1 needed setup or clean up assistance from staff with getting in and out of the shower, eating, and oral hygiene. The MDS indicated Resident 1 required supervision or touching assistance from staff with bathing, and personal hygiene. A review of Resident 2’s Admission Record (Face Sheet) indicated Resident 2, a 60-year-old male, was admitted to the facility on 8/31/2022 with diagnoses including schizophrenia, hearing loss and hypertension. A review of Resident 2’s H&P dated 8/31/2023 indicated Resident 2 was alert and oriented to name, place, and time. A review of Resident 2’s MDS, dated 7/10/2024, the MDS indicated Resident 2 did not require assistance from staff with oral hygiene, toileting hygiene, dressing, putting on and taking off footwear, personal hygiene, repositioning, standing, sitting, transferring to a chair, and transferring to a toilet. The MDS indicated Resident 2 setup or clean up assistance from staff with eating. The MDS indicated Resident 2 needed supervision or touching assistance transferring to the shower, and walking. During a concurrent observation and interview on 8/1/2024 at 10:15 a.m. with Resident 1, in Resident 1’s room, Resident 1 was observed to have one inch long cut on his right index finger. Resident 1 stated that Resident 2 had stabbed him with a pen using a downward motion. During an interview on 8/1/2024 at 10:20 a.m. Resident 2 stated he stabbed Resident 1 three times with a pen in his right index finger. During an interview on 8/1/2024 at 10:25 a.m. the Director of Nursing (DON) stated on 7/17/2024 at 4:35 p.m. Resident 1 had sustained a cut on his right index finger. The DON stated Resident 2 had alleged that Resident 1 was threatening him, leading him to respond aggressively as a dare. Following the incident, Resident 1 received treatment consisting of a triple antibiotic, and the affected area was covered with gauze dressing. The DON also stated that Resident 2 was transferred to a psychiatric hospital for ongoing observation. The DON stated Resident 2 returned to the facility on 7/22/2024 and his medications for schizophrenia were adjusted. During an interview on 8/1/2024 at 10:42 a.m. the Administrator (ADM) stated it was reported to him that during rounds a Certified Nursing Assistant (CNA) noticed a blood on Resident 1’s bed and Resident 1 showed to CNA his hand. The ADM stated Resident 2 stab Resident 1 with a pen on his right index finger. The ADM stated that he concluded the abuse did happen but could not establish why Resident 2 stabbed Resident 1 with a pen. The ADM stated the residents were separated and placed in different rooms. The ADM stated Resident 2 was transferred to the psychiatric General Acute Care Hospital for evaluation and treatment. During an interview on 8/1/2024 at12:10 p.m. the ADM stated residents were allowed to have pens depending on their history of mental illness or aggressive behavior. The ADM stated, “Resident 2 does not have a pen at this time, it was taken away. “The ADM stated, “Resident 2 will need supervision if he wants a pen again.” The ADM stated residents will not be allowed to have a pen if they present a danger. The ADM stated the pen will be taken away from the residents if they pose a danger to someone else. A review of facility’s policy and procedure (P&P) titled “Abuse Prevention and Reporting”, dated 1/30/2024, the P&P indicated, “Any form of mistreatment of residents including but not limited to abuse, neglect, exploitation, involuntary seclusion, misappropriation of property or any crime are strictly prohibited…Abuse - means infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well -being. "Willful" means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.” The facility failed to: 1. Ensure sharp objects including pointed pen and pencils that could potentially use to harm another resident were removed from residents’ belongings. As a result, Resident 2 stabbed Resident 1 on his right index finger repeatedly with a pen. Resident 1 sustained one inch long cut on the right index finger. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.