Other·May 10, 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 3/14/2024 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 1 and Resident 2 had verbal and physical altercation. On 3/28/2024, 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 and verbal abuse. The facility failed to: 1. Ensure Resident 2's whereabouts were supervised continuously to prevent Resident 2 from verbally abusing Resident 1 as indicated in Interdisciplinary Team (IDT) notes dated 2/12/2024 with recommendation to prevent resident-to-resident altercation between Resident 1 and Resident 2. 2. Informed Resident 2's physician to address Resident 2's continued name calling such as fat, ugly and "bitch" towards Resident 1 and staff. 3. Follow its policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation," to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. As a result, Resident 2 verbally and physically abused Resident 1 by calling Resident 1 fat, ugly and "bitch", and hit Resident 1 in the head on 3/14/2024. A review of Resident 1's Admission Record indicated Resident 1, a 61-year-old female, was admitted to the facility on 6/9/2021 with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic kidney disease. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 2/14/2024, indicated Resident 1 had an intact cognitive skills for daily decision making. The MDS indicated Resident 1 needed supervision or touching assistance with eating, bathing, dressing, bed mobility, transfer to and from a bed to wheelchair and personal hygiene. A review of Resident 2's Admission Record , indicated Resident 2, a 72 year old female, admitted to the facility on 6/5/2021 with diagnoses including schizophrenia, (mental illness that affects how a person thinks, feels and behaves) dementia (loss of cognitive functioning such as thinking, remembering and reasoning which can affect and interfere with daily life and activities), and major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest in things and activities). A review of Resident 2's MDS dated 2/14/2024, indicated Resident 2 had an intact cognitive skill for daily decision making. The MDS indicated Resident 2 needed moderate assistance with toileting hygiene, shower, upper body dressing and lower body dressing hygiene. A review of Resident 1's IDT Care Conference dated 2/12/2024 timed at 12:14 p.m., indicated there was a documented recommendation to monitor Resident 1 whereabouts hourly to keep her away from Resident 2 to prevent further physical or verbal altercations and ensure Resident 1's safety. A review of Resident 1's IDT Care Conference Note dated 3/14/2024, and timed at 2:50p.m., indicated a second resident-to-resident verbal and physical altercation between Resident 1 and Resident 2 took place on 3/14/2024. There was a pervious physical and verbal altercation without the injuries between these two residents on 2/12/2024. Resident 1 called Resident 2 a "bitch" and Resident 2 called Resident 1 "you have an ugly face." Resident 1 hit Resident 2, Resident 2 grabbed and pulled Resident 1's hair. The IDT Care Conference Note indicated Resident 2 claimed Resident 1 started the fight by hitting her on her left shoulder but Resident 1 claimed Resident 2 punched her and called her ugly, and "bitch." The IDT Care Conference Note indicated Resident 1 will be closely monitored to ensure she was separated from Resident 2. A review of Resident 1's Care Plan titled "Involved in alleged verbal and physical altercation with Resident 2 on 3/14/2024, the Care Plan goals indicated Resident 1 will not have further verbal or physical altercation from Resident 2. The Care Plan's interventions included to do frequent visual checks to monitor Resident 1's whereabouts and ensure she was always separated from Resident 2. A review of Resident 1's Psychology Note dated 3/19/2024, indicated Resident 1 had difficulties sleep and controlling worries related to recent incident at facility on 3/14/2024 (resident to resident altercation with Resident 2). A review of Resident 2's Nurses Progress Note dated 3/14/2024 and timed at 5:15 p.m., indicated on 3/14/2024 around 11:45 a.m. in the dining room, Resident 1 and Resident 2 were yelling at each other. Resident 2 came up close to Resident 1 and swung her arm at Resident 1's back. A review of Resident 2's IDT Care Conference Note dated 3/14/2024, indicated Resident 2 was sent out to the hospital for psychiatric (focused on treatment and prevention of mental, emotional, and behavioral disorders) evaluation. A review of Resident 2's Care Plan titled "Involvement in resident-to-resident verbal and physical altercation with Resident 1 (this is the second incident of altercation within 60 days) initiated on 3/14/2024, the care plan goal for Resident 2 as to have no further incident of verbal or physical altercation with Resident 1. The Care Plan interventions including 1:1 monitoring of Resident 2 to ensure safety and prevent further altercation. Resident 2 had an order from physician to transfer to a general acute care hospital for evaluation and management of behavior. During an interview on 3/28/2024, at 2:39 p.m. a Certified Nursing Assistant (CNA 1), stated Resident 1 and Resident 2 were roommates last year but were separated because they did not get along well and always bicker (argue). CNA 1 stated verbal abuse was when Resident 2 call Resident 1 "ugly, bitch, and fat." During an interview on 3/28/2024, at 4 p.m. Registered Nurse Supervisor (RNS 1), stated one of their interventions to prevent occurrence of altercation between Resident 1 and Resident 2 was to monitor their locations. RNS 1 stated licensed nurses, and certified nursing assistants' responsibilities were to ensure Resident 1's and Resident 2's whereabouts were monitored to prevent them to be near each other. RNS 1 stated monitoring of Resident 1 and Resident 2 should be documented in a log. RNS 1 stated there was no documentation about monitoring of both residents' location or whereabouts and stated if it was not documented meant it was not done. RNS 1 stated verbal abuse was when a resident would say words like fat, ugly, and "bitch" towards staff and Resident 1. RNS 1 stated these words could affect the emotional state of Resident 1. Resident 1 could feel unsafe when she was in close proximity with Resident 2. During an interview on 3/28/2024, at 2:07 p.m. CNA 2 stated Resident 2 would sometimes tell CNA 2 she was ugly and would grab her hair. During an interview on 3/28/2024, at 12:00 p.m. Activity Assistant (AA 1), stated when Resident 2 would not get what she wanted Resident 2 would say "you are ugly or fat." AA 1 stated Resident 2 saying words such as ugly and "bitch" towards Resident 1 was a form of verbal abuse and when Resident 2 hit Resident 1 that was a physical abuse. During an interview on 3/29/2024, at 3:19 p.m., the Social Services Director (DSS) stated Resident 1 and Resident 2 could retaliate with each other and will get hurt if they continue to have altercation in the facility. During an interview on 3/28/2024, at 4:18 p.m. the Licensed Vocational Nurse (LVN 1) stated if Resident 2's calling Resident 1 fat, ugly and "bitch," it was considered a behavioral manifestation of verbally abusive behavior and should have been reported to the physician right away because it needed to be addressed. A review of facility's P&P titled "Abuse, Neglect and Exploitation" revised 12/19/2022, the P&P indicated the facility will implement P&P to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves identification, ongoing assessment, care planning for appropriate interventions and monitoring of resident with needs and behaviors that might lead to conflict. The P&P indicated the facility will increase supervision of the alleged victim and residents and revision of resident's care plan if changed because of an incident of abuse. The facility failed to: 1. Ensure Resident 2's whereabouts were supervised continuously to prevent Resident 2 from verbally abusing Resident 1 as indicated in Interdisciplinary Team (IDT) notes dated 2/12/2024 with recommendation to prevent resident-to-resident altercation between Resident 1 and Resident 2. 2. Informed Resident 2's physician to address Resident 2's continued name calling such as fat, ugly and "bitch" towards Resident 1 and staff. 3. Follow its P&P titled, "Abuse, Neglect and Exploitation," to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. As a result, Resident 2 verbally and physically abused Resident 1 by calling Resident 1 fat, ugly and "bitch", and hit Resident 1 in the head on 3/14/2024. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.