Health inspection·November 20, 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 10/15/2024 the California Department of Public Health (CDPH) received a facility reported incident (FRI) during an annual Recertification Survey of the facility alleging that on 10/11/2024 Resident 65 was hit with a bedside table. The facility failed to: 1. Ensure Resident 65 was free from physical abuse from Resident 37 who hit Resident 65's with a bedside table. 2. Ensure Resident 37 was assess and monitor when Resident 37 exhibited aggressive behavior towards Restorative Nursing Assistant (RNA 1) to deescalate Resident 37's aggressive behavior in effort to prevent physical abuse toward Resident 65. As a result, Resident 37 hit Resident 65 in the head with a bedside table and sustained a small cut to her right forehead. A review of Resident 65's Admission Record indicated Resident 65, a 73-year-old female, was admitted to the facility on 1/26/2015 with diagnoses including paranoid schizophrenia (mental illness characterized by a pattern of behavior where a person feels distrustful and suspicious of other people and surroundings) and unspecified dementia (a progressive stated of decline in mental abilities) without behavioral disturbance. A review of Resident 65's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/30/2024, indicated Resident 65 had an intact cognition (ability to think, understand, learn, and remember) and was independent with bed mobility, walking and transfer to and from a bed to a chair. A review of Resident 65's Post Event Assessment Form dated 10/11/2024, indicated on 10/11/2024, at 3:00 p.m., Resident 65 came to the nursing station asking for help. Resident 65 was observed bleeding on her right forehead. A review of Resident 65's Nurses Progress Notes dated 10/11/2024, timed at 3:00 p.m., indicated Resident 65 came to the nursing station asking for help and was observed bleeding on the right side of her forehead. The Nurses Progress Notes indicated Resident 37 threw a bedside table towards Resident 65 when Resident 65 was passing by Resident 37's bed which caused the bedside table to hit her. A review of Resident 37's Admission Record indicated Resident 37, a 66-year-old female, was admitted to the facility on 1/31/2023 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 37's MDS dated 8/10/2024, indicated Resident 37 was able to make herself understood and able to understand others. The MDS indicated Resident 37 had moderately impaired cognitive skill and was independent with bed mobility, walking and transferring to and from a bed to a chair. A review of Resident 37's Post Assessment Event Form dated 10/11/2024, timed at 6:11 p.m., indicated on 10/11/2024, at 3:00 p.m. Resident 37 was exhibiting delusional ( having false or unrealistic beliefs) thinking and stated "Love, I was asleep and the two ladies came up to me and one of them put her thumb up my butt and with her other hand took out my fetus, it's still there outside you can see it, then the other one came with razor blades and cut my face, see all this blood and look at my back they did a number on me." Resident 37 expressed remorse for inadvertently harming Resident 65 and stated, "I am so sorry honey, you should not be getting in people's way when they are upset, I did not mean to hit you." A review of Resident 37's Psychiatric Notes dated 10/11/2024 timed at 3:48 p.m., indicated Resident 37 was seen in her room with paranoid delusional (a type of delusion that involve intense fear and anxiety and the belief that others are persecuting or threatening) content and accusing roommate to have caused her to have miscarriage. The Psychiatric Notes indicated Resident 37 was involved in two physical incidents on 10/11/2024, first one was with staff who was hit on the right arm (no time documented) and the second incident was Resident 37's roommate whom the resident hit on the right side of the forehead (no time documented). A review of Resident 37's Care Plan titled, "Resident is at risk for further escalating (worsening) behavior related to bizarre delusions, initiated 10/11/2024, with goals for Resident 37 to have no episodes of escalating aggressive behavior. The Care Plan interventions included the staff to anticipate the resident escalating behavior, monitor for increased agitation and to notify the psychiatrist if observed. During a concurrent observation and interview on 10/15/2024 at 10:43 a.m., in Resident 65's room, Resident 65 was observed with a band-aid on the right side of her forehead. During an interview on 10/16/2024, at 9:31 a.m., Resident 37 stated she got in a fight with her roommate and hit her with the bedside table. Resident 37 stated Resident 65 had a little bruise and cut on her forehead. During an interview on 10/16/2024 at 1:14 p.m., a Certified Nursing Assistant (CNA 8), stated Resident 37 had behavioral issues including slamming door, talking loudly, asking staff to get out of the room and throwing things on the floor. CNA 8 stated Resident 37 liked to strip linens from her bed then toss the beddings or clothes on the floor. During an interview on 10/16/2024, at 3:24 p.m., the Registered Nurse Supervisor (RNS 1) stated Restorative Nursing Assistant (RNA 1) told RNS 1 that Resident 37 hit her right arm while Resident 37 was walking back to her room. RNS 1 stated Resident 37 slammed the door after entering her room and shortly after that Resident 65 came out of the room and asking for help. RNS 1 stated Resident 65 was holding her head and was bleeding on the right side of the forehead. RNS 1 stated Resident 65 was not manifesting any behavioral problem on 10/11/2024 (day of incident) and Resident 37 was seen talking to herself but was in good mood. RNS 1 stated staff should have followed Resident 37 to her room after she hit RNA 1 on her arm and slammed her bedroom door to ensure Resident 37 was not a threat to other residents. RNS 1 stated staff should have monitor Resident 37's behavior and prevent it from escalating. During an interview on 10/18/2024, at 10:44 a.m., the Assistant Director of Nursing (ADON)stated the incident between Resident 65 and Resident 37 could have been prevented if the staff followed Resident 37 to her room when Resident 37 hit RNA 1 on her arm before heading to her room and slammed the door. Staff should have assessed and monitored Resident 37's aggressive behavior and attempted to deescalate the situation. The ADON stated that staff should have spoken to Resident 37 when she was exhibiting aggressive behavior. The ADON stated the incident between the residents was preventable if staff had come to the room when Resident 37 hit RNA 1 on her way to her room and slammed the door to assess and monitor Resident 37's aggressive behavior and try to deescalate the situation. ADON stated someone should have talked to Resident 37 when she was manifesting aggressive behavior. During an interview on 10/18/2024, at 12:22 p.m., the Social Service (SS1) stated Resident 37 was upset and threw a bedside table at Resident 65 who was in the room. SS 1 stated Resident 37's behavioral symptoms were physical aggression (act of intentionally harming or threatening to harm someone through physical means ), verbal aggression (use of words or gestures to intentionally cause psychological harm to another person), auditory hallucinations (hearing sounds or voices or music that are not there), paranoid delusions (fixed beliefs that some is hurting or persecuting oneself even no evidence to support), and disorganized thoughts (incoherent and illogical thoughts and behavior) . SS 1 stated paranoia (mental disorder that involves an irrational, persistent fear, and distrust of others) triggered the aggression of Resident 37. SS 1 stated the nursing staff should have followed Resident 37 to her room after she hit RNS 1 on her arm and slammed her bedroom door. SS 1 stated this would allow the staff to assess and address Resident 37's aggressive behavior, helping to prevent escalation and potential harm to herself and other residents. During an interview on 10/18/2024, at 12:54 p.m., SS 2 stated Resident 65 had no history of aggressive behavior towards other residents. During an interview on 10/18/2024, at 5:07 p.m., the Director of Nursing (DON)stated Resident 37's behavior was unpredictable, and a staff member should have immediately followed and entered Resident 37's room when Resident 37 hit RNA 1 and slammed her bedroom door to assess and monitor her aggressive behavior defuse Resident 37's delusions. The DON stated the staff should have monitor Resident 37, calmed her down and redirect her to prevent Resident 37 throwing the table towards Resident 65. A review of facility's policy and procedure (P&P) titled "Abuse Prevention and Reporting " approved on 1/30/2024, the P&P indicated the facility is committed in protecting the physical and emotional well-being of every resident. The P&P indicated the staff is required to intervene, identify, and correct situations where any type of abuse or suspected crimes may occur. The facility failed to: 1. Ensure Resident 65 was free from physical abuse from Resident 37 who hit Resident 65's with a bedside table. 2. Ensure Resident 37 was assess and monitor when Resident 37 exhibited aggressive behavior towards RNA 1 to deescalate Resident 37's aggressive behavior in effort to prevent physical abuse toward Resident 65. As a result, Resident 37 hit Resident 65 in the head with a bedside table and sustained a small cut to her right forehead. These violations had a direct or immediate relationship to the health, safety, or security of Resident 65.