Health inspection·December 28, 2023

Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 22 CCR §72311 Nursing Service - General (Title 22 reference) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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. The California Department of Public Health (CDPH) received a facility reported incident (FRI) on 11/27/2023 indicating three residents (Resident 1, Resident 2, and Resident 3) were observed having a physical altercation in the “park” during a cigarette break. The FRI alleges once staff arrived, Resident 2 was observed holding Resident 1 at the head. On 11/30/2023, the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Implement its Policy and Procedure (P &P) titled “Abuse prevention,” which indicated residents will be protected from abuse by anyone including staff and other residents, when Resident 1 attached Resident 2 and 3. 2. Follow its P &P titled “Care Plans, Comprehensive Person-Centered” which indicated the facility will develop and implement a comprehensive person-centered care plan for each resident and update the care plan when there was a significant change in the resident’s condition. Resident 1 had a altercation with Resident 2 on 11/26/2023 at 2:41 pm, but the facility did not develop a care plan to address Resident 1’s episode of verbal aggression towards other residents. As a result, staff did not monitor residents in the smoking patio and Residents 1, 2 and 3 had a physical altercation on 11/26/2023 at 7:05 pm. A. A review of Resident 1’s Admission Record indicated Resident 1, was a 68-year-old male, who was admitted to the facility on 9/5/2023. with diagnoses that included encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition, sometimes causing a declined ability to reason and concentrate, memory loss, and personality changes) and altered mental status. A review of Resident 1’s History and Physical (H&P), dated 9/6/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/14/2023, indicated Resident 1 did not have any cognitive impairments (trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required limited assistance of a one person physical assist with transfers, walking in the room, corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 1’s “Change in Condition Evaluation,” dated 11/26/2023 at 2:41 PM, indicated on 11/26/2023 at 2:40 PM , Resident 1 was verbally aggressive towards other residents. The assessment indicated a behavioral and neurological assessment were not clinically applicable to the change in condition being reported. A review of Resident 1’s care plans indicated the facility did not address Resident 1’s verbal aggression on 11/26/2023 at 2:40 PM, or any interventions to prevent further aggressive behaviors towards other facility residents. A review of Resident 1’s “Change in Condition Evaluation,” dated 11/26/2023 at 8:02 PM, indicated Resident 1 was had a physical altercation on 11/26/2023 at 7:05 PM. With Resident 2 and Resident 3. The assessment further indicated a behavioral and neurological assessment were not clinically applicable to the change in condition being reported. During an interview on 12/1/2023 at 9:20 AM, Resident 1 stated he did not recall any facility staff present on the patio at the time of the physical altercation on 11/26/2023. Resident 1 stated he had a verbal altercation with a resident, whose name he could not recall, and then, a physical altercation with Resident 2 and Resident 3. B.A review of Resident 2’s Admission Record indicated Resident 2, was a 50-year-old male, admitted to the facility with diagnoses including schizophrenia (mental illness), unsteadiness on the feet, and generalized muscle weakness. A review of Resident 2’s H&P, dated 8/10/2023, indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2’s MDS, dated 9/8/2023, indicated Resident 2 had no cognitive impairments and did not exhibit any evidence of disorganized thinking, hallucinations, or delusions. The MDS indicated Resident 2 required a one-person physical assist with bed mobility, transfer, walking in the room, corridor, and locomotion on and off the unit, toilet us, personal hygiene, and dressing. A review of Resident 2’s “Change in Condition” Evaluation, dated 11/26/2023 at 8:53 p.m., indicated on 11/26/2023 at 7:05 p.m., Resident 2 was involved in a physical altercation on the patio with Resident 1 and Resident 3. The residents were separated and the police were called and the physician was notified. Resident 2 denied any pain or injuries. C. A review of Resident 3’s Admission Record indicated Resident 3, was a 44-year-old male, who was admitted to the facility on 6/12/2023 with diagnoses including polyneuropathy (a disease of, or damage to nerves), generalized muscle weakness, and abnormalities of gait and mobility. A review of Resident 3’s H&P, dated 6/13/2023, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3’s MDS, dated 9/21/2023, indicated Resident 3 had no cognitive impairments and did not exhibit any evidence of disorganized thinking, hallucinations, or delusions. The MDS indicated Resident 3 required supervision with walking in the room, corridors, and locomotion on and off the unit. A review of Resident 3’s “Change in Condition” Evaluation, dated 11/26/2023 at 9:03 p.m., indicated on 11/26/2023 at 7:05 p.m., a nurse observed Resident 1 physically harming Resident 2 and Resident 3. The residents were separated and the police were called and the physician was notified. Resident 3 denied any injuries or pain at the time. During an interview on 12/1/2023 at 9:50 AM, Resident 3 stated Resident 1 had been verbally aggressive to other residents the afternoon of 11/26/2023 while on the smoking patio. Resident 3 stated later that day, Resident 1 attempted to strike him and Resident 2 with his fists and cane while they were in the smoking patio. Resident 3 stated there were no staff monitoring Resident 1, or supervising the other residents in the smoking patio, at the time of the physical altercation. Resident 3 stated the altercation had been happening for about ten minutes prior to facility staff’s arrival to separate the residents. Resident 3 stated Resident 1 was angry and attempted to strike other residents on the patio and Resident 3 tried to de-escalate the situation because there were no staff available to help. Resident 3 stated, Resident 1 then attacked him. A review of the facility’s “Supervision Smoking Schedule,” dated 11/29/2023, the schedule indicated Resident 1, 2, and 3 were all allowed to smoke on the patio without supervision. During a concurrent interview and record review, on 12/1/2023 at 11:20 AM, with the Director of Staff Development (DSD), Resident 1’s “Change in Condition Evaluation,” dated 11/26/2023 and care plan titled, “Risk for emotional distress related to physical altercation,” were reviewed. The DSD stated Resident 1’s care plan was supposed to be updated to reflect the verbal aggression towards other residents, and interventions to address the behavior. The DSD stated interventions should have included staff monitoring of Resident 1 for a minimum of 72 hours, even if his smoking assessment indicated he could smoke independently. The DSD sated verbal aggression could escalate to physical aggression, and place other residents at risk for harm. The DSD stated the care plan would have alerted to staff of the need to monitor Resident 1, and the physical altercation with Residents 2 and 3, could have been prevented. During an interview on 12/1/2023 at 11:52 AM, Registered Nurse Supervisor (RNS) 2, stated he was one of the supervisors in charge on the evening of 11/26/2023. RNS 2 stated he was unaware Resident 1 had been verbally aggressive towards other residents earlier that day. RN 2 stated he was unaware of a care plan for Resident 1’s verbal aggression did not know Resident 1 was supposed to be monitored for verbal aggression. RNS 2 stated it was important for staff to monitor Resident 1, to prevent the escalation from verbal to physical aggression. RN 2 stated there were no staff in the patio supervising the residents at the time of the altercation. RNS 2 stated a care plan could have alerted him of Resident 1’s behavior, and to ensure staff were supervising Resident 1 on the patio. RNS 2 stated the physical altercation, and the potential physical and psychosocial harm to the involved residents, could have been avoided if Resident 1’s care plan had been updated. During an interview on 12/1/2023 at 12: PM, the Director of Nursing (DON), stated Resident 1’s care plan was supposed to be updated following his verbal aggression toward other residents. The DON stated the purpose of a care plan was to identify the plan of care for residents, to ensure staff were aware of any necessary monitoring requirements. The DON stated the physical altercation between Residents 1, 2, and 3 could have been avoided if Resident 1’s care plan was updated and staff aware to monitor Resident 1. A review of the facility's policy and procedure (P&P) titled, “Abuse prevention,” dated 12/2016, indicated residents will be protected from abuse by anyone including staff and other residents. A review of the facility's P&P titled, “Abuse and Neglect – Clinical Protocol,” dated 3/2018, indicated “the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse.” A review of the facility's P&P titled, “Resident-to-Resident Altercations,” dated 12/2016, indicated “if two residents are involved in an altercation, staff will make any necessary changes in the care plan…to any or all of the involved individuals.” A review of the facility P&P titled, “Care Plans, Comprehensive Person-Centered,” dated 12/2016, indicated “care plans are revised as information about the residents and the residents’ conditions change”. The P&P further indicated “the interdisciplinary team must review and update the care plan when there has been a significant change in the resident’s condition.” A review of the facility P&P titled, “Safety and Supervision of Residents,” dated 12/2007, indicated “resident safety and supervision and assistance to prevent accidents are facility-wide priorities”. The P&P further indicated “resident supervision is a core component…to safety. The type and frequency of resident supervision is determined by the individual resident’s assessed needs and identified hazards…”. The P&P further indicated “the interdisciplinary care team shall analyze information obtained from assessments and observations to identify specific accident hazards or risks for that resident” and “implement interventions to reduce accident risks and hazards.” A review of the facility P&P titled, “Behavioral Assessment, Intervention, and Monitoring,” dated 3/2015, indicated “behavioral symptoms will be managed appropriately” and indicated management included an evaluation of the resident’s behavioral symptoms and staff were expected to “develop a plan of care accordingly”. The P&P further indicated “the care plan will include, as a minimum…a description of the behavioral symptoms” and “…targeted and individualized interventions.” The facility failed to: 1. Implement its Policy and Procedure (P &P) titled, “Abuse prevention,” which indicated residents will be protected from abuse by anyone including staff and other residents, when Resident 1 attached Resident 2 and 3. 2. Follow its P &P titled “Care Plans, Comprehensive Person-Centered” which indicated the facility will develop and implement a comprehensive person-centered care plan for each resident and update the care plan when there was a significant change in the resident’s condition. Resident 1 had an altercation with Resident 2 on 11/26/2023 at 2:41 pm, but the facility did not develop a care plan to address Resident 1’s episode of verbal aggression towards other residents. As a result, staff did not monitor residents in the smoking patio and Residents 1, 2 and 3 had a physical altercation on 11/26/2023 at 7:05 pm. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.