Health inspection·May 10, 2024

42 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. (a)The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. 22CCR §72311. Nursing Service – General. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. 22CCR §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. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. 22 CCR § 72527. Patient’s 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. The California Department of Public Health (CDPH) received an Entity Reported Incident (ERI) on 3/14/2024, indicating Resident 1 struck Resident 2 in the arm. On 3/14/2024, the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Follow Resident 1’s Care Plan dated, 2/12/2024 to address the resident’s episodes of mood swings, rapid fluctuations of emotion ranging from calmness to anger on 3/4/2024, 3/7/2024, 3/10/2024 and 3/11/2024.   2. Revise and individualize the Care Plan for Resident 1, who had a history of altercations and aggressive behavior. 3. Follow its Policy and Procedure (P&P) titled, “Abuse Prevention/Prohibition” dated, 11/2018, which indicated the facility did not condone any form of resident abuse. As a result, Resident 2, was physically abused by Resident 1 and had the potential to result in Resident 2 sustaining injuries and negatively affect the resident’s psychosocial well-being. Findings: Resident 1 was a 64-year-old female, admitted to the facility on 8/16/2021 and readmitted on 2/12/2024, with diagnoses including schizoaffective disorder (mental health condition characterized by symptoms such as hallucinations [hearing, seeing, smelling, tasting or feeling things that were not real], mania [abnormally elevated, extreme changes in mood] and depression [persistent feeling of sadness and loss of interest]), anxiety disorder (mental health condition characterized by feelings of worry or fear), and dementia (loss of memory, language, problem-solving and other thinking abilities).  A review of Resident 1’s Care Plan for behavior dated 2/12/2024, indicated Resident 1 had behavioral symptoms manifested by hallucinations (visual and auditory), mood swing as evidenced by (AEB) rapid fluctuation of emotion ranging from calmness to anger and crawling out of bed. The Care Plan indicated approaches and plan included to provide behavioral management or modification as needed, such as finding out the reason for behavior and provide interventions as needed, providing redirection when exhibiting inappropriate behavior and monitor the resident’s interaction with another resident to prevent offensive behavior. A review of Resident 1’s physician orders dated 2/13/2024, indicated to monitor Resident 1 for bipolar disorder (condition associated with episodes of mood swings ranging from depressive lows to manic highs) manifested by mood swings AEB rapid fluctuations of emotion ranging from calmness to anger every shift. A review of Resident 1’s Department Notes indicated there was no documentation to indicate Resident 1’s mood swings and behaviors were addressed according to Resident 1’s Care Plan. A review of Resident 1's Minimum Data Set ([MDS] an assessment and care screening tool), dated 2/21/2024, indicated Resident 1 required substantial/maximal assistance with Activities of Daily Living (ADLs) such as dressing, toilet use, personal hygiene, transfer (how resident moved between surfaces) and bed mobility (how resident moved from lying to turning side to side). A review of Resident 1's History and Physical (H&P), dated 3/6/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Medication Administrator Record (MAR) dated 3/2024 indicated Resident 1 was being monitored for bipolar disorder manifested by mood swings AEB rapid fluctuations of emotion ranging from calmness to anger every shift. The MAR indicated Resident 1 had two episodes on 3/4/2024 during the day shift, one episode on 3/7/2024 during the evening shift, two episodes on 3/10/2024 during the night shift and one episode on 3/11/2023 during the day shift. A review of Resident 1’s Situation, Background, Assessment and Recommendation (SBAR) dated 3/13/2024 at 4:05 p.m. indicated Resident 1 was sitting in the doorway of the Medical Records office when another resident (Resident 2) came from behind to forcefully move Resident 1, and Resident 1 hit Resident 2 on his hands and wrist with a closed hand. The SBAR indicated Resident 1 had a history of altercations. Resident 2 was an 88-year-old male, admitted to the facility on 10/10/2023 with diagnoses including major depressive disorder (type of depression), anxiety disorder and Schizophrenia. A review of Resident 2’s H&P dated 2/13/2024 indicated Resident 2 had fluctuating mental capacity to understand and make medical decisions. A review of Resident 2’s MDS, dated 1/15/2024 indicated Resident 2 required set up or clean-up assistance with ADLs such as dressing toilet use, personal hygiene, transfer, and bed mobility. During an interview on 3/15/2024 at 11:40 a.m., Certified Nurse Assistant (CNA) 3 stated, Resident 1 was confused and had episodes of anger and calmness. CNA 3 stated Resident 1 was unpredictable with her behavior. During an interview on 3/15/2024 at 1:40 p.m., Registered Nurse (RN) stated, Resident 1 would follow directions intermittently, was unpredictable and moods changed frequently. During a concurrent Record Review and interview on 4/10/2024 at 1:52 p.m., the Director of Nursing (DON) stated, Resident 1 was the perpetrator of three resident-to-resident altercations on 2/7/2024, 3/2/2024 and 3/13/2024. The DON stated, Resident 1’s Care Plans should have been revised and individualized after the altercation on 3/2/2024, however was not done. The DON stated, it was important to revise and individualize the resident’s care plan to customize the care to the resident’s need, prevent future occurrences of abuse and ensure residents were provided a safe environment. During a record review and interview on 4/10/2024 at 2:10 p.m. the DON stated, Resident 1 had a physician’s order to be monitored for mood swings from calmness to anger every shift. The DON stated, there was no supporting documentation to indicate resident’s specific behavior, incidents, interventions or follow up was done for Resident 1’s observed mood swings on 3/4/2024, 3/7/2024, 3/10/2024 and 3/11/2024. The DON stated, it was important to document the resident’s behaviors and incidents observed, to ensure the issues were addressed and to give a better picture to the doctor when evaluating the resident’s plan of treatment. The DON stated it was also important to ensure immediate issues were addressed and communicated to the care team. A review of the facility’s P&P titled, “Care Plans-Comprehensive” dated 9/2010 indicated, an individualized comprehensive care Plan that included measurable objectives and timetables to meet the resident’s medical, nursing, mental and psychological needs were developed for each resident. The P&P indicated Assessments of residents were ongoing and Care Plans were revised as information about the resident and the resident’s condition changed. The P&P indicated the Care Planning/Interdisciplinary Team were responsible for the review and updating of the updating of the Care Plans: when there was a significant change in the resident’s condition and when the desired outcome was not met. A review of the facility’s P&P titled, “Abuse Prevention/Prohibition” dated 11/2018, indicated the facility did not condone any form of resident’s abuse, neglect, misappropriation of the resident’s property, developed policies and procedures, training programs and systems to promote an environment free from abuse and mistreatment. The P&P indicated, the facility conducted mandatory facility staff training programs on prohibiting and preventing all forms o abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. A review of the facility’s P&P titled, Behavioral Assessment, Intervention and Monitoring” dated 3/2019 indicated, the Interdisciplinary team would evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. The P&P indicated safety strategies would be implemented immediately if necessary to protect the resident and others from harm. The facility failed to: 1. Follow Resident 1’s Care Plan dated, 2/12/2024 to address the resident’s episodes of mood swings, rapid fluctuations of emotion ranging from calmness to anger on 3/4/2024, 3/7/2024, 3/10/2024 and 3/11/2024.   2. Revise and individualize the Care Plan for Resident 1, who had a history of altercations and aggressive behavior. 3. Follow its P&P titled, “Abuse Prevention/Prohibition” dated, 11/2018, which indicated the facility did not condone any form of resident abuse. As a result, Resident 2, was physically abused by Resident 1 and had the potential to result in Resident 2 sustaining injuries and negatively affect the resident’s psychosocial well-being. These violations had a direct or immediate relationship to the health, safety or security of Resident 2.