Health inspection·November 8, 2024

Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(a) The facility must: 42 CFR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CFR § 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. 22 CFR § 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. 22 CFR § 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. On 10/7/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding a resident to resident altercation. On 10/22/2024, the CDPH conducted an unannounced DRI investigation at the facility. The facility failed to: 1. Ensure Resident 1 was free from physical abuse by Resident 2. As a result, Resident 2 hit Resident 1 with a cone-shaped wet floor sign. Resident 1 was a 58- year-old male admitted to the facility on 9/14/2024 with diagnoses including diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that can affect thoughts, mood, and behavior), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN- high blood pressure). A review of Resident 1’s Minimum Data Set ([MDS] – a federally mandated resident assessment tool), dated 9/21/2024, indicated Resident 1’s cognitive (the ability to think and process information) skills for daily decisions making was intact. The MDS indicated Resident 31 required supervision assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1’s progress note, dated 10/5/2024 at 7:55 a.m., indicated Resident 1 was hit with a wet floor sign by his roommate (Resident 2) which caused a bruise and cut on the right elbow. During an interview on 10/21/2024 at 1:10 p.m., Resident 1 stated on 10/5/2024 in the early morning hours (was not able to recall the time), his roommate (Resident 2) was “passing gas” and was acting very unpleasant. Resident 1 stated he (Resident 1) asked Resident 2 to stop passing gas and go into the bathroom. Resident 1 stated Resident 2 was upset and ran out of the room, grabbed a wet floor sign, and threw it at Resident 1. Resident 1 stated he was hit on his right elbow. Resident 1 stated he had a right elbow cut and bruise. Resident 1 stated he felt threatened and scared for his life. Resident 2 was a 59-year-old male originally admitted to the facility on 8/1/2018 and readmitted on 6/14/2024 with diagnoses including schizophrenia, anxiety (feeling of fear, dread, and uneasiness), and hypertension. A review of Resident 2’s MDS, dated 9/21/2024, indicated Resident 2’s cognitive skills for daily decisions making was moderately impaired. The MDS indicated Resident 2 was independent for ADLs. A review of Resident 2’s situation, background, recommendation ([SBAR]- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/5/2024 at 8:15 a.m., indicated Resident 1 and 2 had an altercation. The SBAR indicated Resident 2 hit Resident 1 with a wet floor sign and Resident 1 sustained a right elbow cut. During a telephone interview on 10/22/2024 at 2:17 p.m., Registered Nurse (RN 1) stated on the morning of 10/5/2024, he (RN 1) was in the conference room and heard yelling and screaming coming from the hallway. RN 1 stated he left the conference room and observed Resident 2 running after Resident 1 while holding a wet floor sign. RN 1 stated, Resident 1 looked scared. RN 1 stated Resident 1 told him (RN 1) that Resident 2 threw the sign and hit him (Resident 1) on the right elbow. RN 1 stated Resident 1 sustained a right elbow skin cut and a bruise. RN 1 stated the wet floor sign was left unattended in front of Resident 1 and 2’s room. RN 1 stated physical abuse could have been prevented if the sign was not left unattended in front of the residents’ room. During a concurrent observation and interview on 10/22/2024 at 2:52 p.m. with RN 2, in the hallway, a wet floor sign was observed unattended in front of a resident’s room. RN 2 stated the wet floor signs left unattended was a safety issue and had the risk for resident-to-resident physical harm, abuse, and injury. A review of the facility’s policy and procedure (P&P) titled “Policy on patient abuse and mistreatment”, dated 10/2022, indicated the facility would uphold resident’s rights to be free from physical abuse (defined as the willful infliction of injury, unreasonable confinement or punishment with resulting physical harm or pain or mental anguish or derivation by an individual). The P&P indicated residents would not be subjected to abuse by another resident. A review of the facility’s P&P tilted “Safety of Residents” revised 5/1/2023, indicated the facility would provide a safe environment for residents. The facility failed to: 1. Ensure Resident 1 was free from physical abuse by Resident 2. As a result, Resident 2 hit Resident 1 with a cone-shaped wet floor sign. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.