Health inspection·October 8, 2024

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved §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 8/19/2024 through 8/21/2024, the California Department of Public Health (CDPH) received a three complaints and a Facility Reported Incident (FRI) alleging a resident (Resident 1) was punched in the nose by another resident (Resident 2). On 8/22/2024 CDPH conducted an unannounced visit to the facility to investigate the complaint allegation and FRI report of abuse. During the investigation, CDPH determined Resident 1 was sitting on the facility's patio next to Resident 2 during a smoking break. Resident 1 asked Resident 2 to move away from her as she elbowed Resident 2, Resident 2 responded by elbowing Resident 1 in her nose. The facility failed to: 1. Ensure Resident 1 and Resident 2 were monitored during a smoking break while on the facility's patio by at least two facility staff, per the Director of Nursing (DON), in order to prevent a physical altercation between Resident 1 and Resident 2 2. Report a physical altercation that occurred between Resident 1 and Resident 2 to the CDPH within two hours of the incident. On 8/18/2024 at approximately 8 a.m., facility staff witnessed Resident 2 elbow Resident 1 in her nose, however, the facility did not report the resident-to-resident altercation to the CDPH until 8/18/2024 at 11:55 p.m. (approximately 16 hours after the incident occurred). 3. Ensure their Policy and Procedure (P/P), titled "Abuse Reporting and Response" that indicated all alleged violations involving abuse are reported immediately but no later than two hours after allegation was made, and their P/P, titled, "Abuse Prevention and Investigation" that indicated will not condone resident abuse by anyone including other residents were followed. These failures resulted in: 1. Resident 1 sustaining a nose fracture (broken nose) and being transfer to a General Acute Care Hospital (GACH) where Resident 1 underwent a reduction of her nasal bones (a medical procedure that realigns [restores to a former position] broken nasal bones back into place), and compression with rightward pressure (a technique used to repair a nasal fracture) to repair/straighten her nasal deviation (occurs when the nasal septum [the boney structure that separates the nasal cavity into two sides, the right and left nostrils] is significantly displaced to one side, making one nasal air passage smaller than the other. 2. CDPH being unaware of the abuse incident and injury to Resident 1, which had the potential for a delay in CDPH's investigation and other abuse to occur and allegations of abuse to go unreported. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 67 year-old female, was initially admitted to the facility on 1/16/2023 and readmitted on 11/24/2023 with diagnosis including dementia (loss of thinking, remembering, reasoning), bipolar disorder (mental disorder that causes a shift in mood and behavior) and schizophrenia ( mental disorder that affects how someone thinks, feels, behaves). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/26/2024, indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 had hallucinations (seeing and hearing things that are not there) and delusions (false belief). A review of Resident 1's undated Situation Background Assessment Recommendation ([SBAR] a form of communication between members of a health care team), indicated on 8/18/2024 at approximately 8 a.m., Resident 1 was involved in a resident-to-resident physical altercation with injury. The SBAR indicated Resident 1 was noted to have purple discoloration to the bridge of her nose, with epistaxis (nose bleed) and deviation with pain rated a 10 out of 10 on a pain rating scale (an 11 eleven point scale where pain in rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). A review of Resident 1's Nurses Progress Notes dated 8/18/2024 and timed at 8:45 a.m., indicated at 8:05 a.m., on 8/18/2024, Resident 1 was observed sitting on a bench close to Resident 2. The Nurses Progress Notes indicated Resident 1 told Resident 2 to stay away from her, "don't move any closer," and then Resident 1 elbowed Resident 2, Resident 2 then elbowed Resident 1 in her nose. A review of Resident 1's Physician's Orders dated 8/18/2024 and timed at 8:45 a.m., indicated an order to transfer Resident 1 to a GACH via ambulance for further evaluation related to Resident 1's nose injury. A review of the GACH's Computerized Tomography ([CT] a medical procedure that uses a computer to create detailed pictures of the inside of the body) report, dated 8/18/2024, of Resident 1's head, indicated Resident 1 sustained a fracture and deformities to her bilateral (affecting both sides) nasal bones and the frontal process of the maxilla (bone in the upper jaw that forms roof of mouth, eye socks and nose) was noted with overlying soft tissue swelling. A review of the GACH's Emergency Department Documentation notes, dated 8/18/2024, indicated Resident 1 underwent a reduction of the nasal deviation. During a concurrent observation and interview on 8/22/2024 at 8:30 a.m., Resident 1 was observed, in her room, with yellowish-bluish discoloration on the bridge of her nose, and on both of her cheeks extending under both eyes. Resident 1 stated she was punched in the face the other day (8/18/2024) by Resident 2. During an interview on 8/22/2024 at 1:47 p.m., Certified Nurse Assistant (CNA 1), stated she was assigned to monitor the patio on 8/18/2024. CNA 1 stated the monitor sits at the exit at the top of the stairs looking down on the patio area. CNA 1 stated on 8/18/2024 at approximately 8 a.m., she observed Resident 1 and Resident 2 sitting on a bench less than an arms' length apart. CNA 1 stated she observed and heard Resident 1 tell Resident 2 to move away, when Resident 2 did not comply, Resident 1 elbowed Resident 2 who then reacted by elbowing Resident 1 in the nose. During an interview on 8/23/2024 at 9:43 a.m., Registered Nurse (RN 1), stated he was the supervising nurse on 8/18/2024, and at approximately 8 a.m., CNA 1 called him to the patio to assess Resident 1. RN 1 stated he observed Resident 1 with blood running from her nose, a purple discoloration on the bridge of her nose and her nose appeared to be deviated toward one side of her face. RN 1 stated he immediately notified the Director of Nursing (DON) and the Administrator (ADM) of the incident via telephone. During an interview on 8/23/2024 at 3:10 p.m., the DON stated all residents have the right to be free from abuse. The DON stated Resident 1 and Resident 2's altercation could have been prevented if the residents were directed to sit further apart. The DON stated one staff person was assigned to the patio during non-smoking hours and two staff persons should have been assigned during smoking hours. The DON stated at the time of Resident 1 and Resident 2's altercation, residents were beginning to arrive for their scheduled smoking time and the second staff person had not arrived at the patio yet. The DON stated she did not report the incident of abuse immediately nor within the regulated two hours because she was busy attending to the needs of Resident 1 and Resident 2. The DON stated failure to report abuse can cause a delay in the investigation of the CDPH and was a violation of the Federal regulations. During an interview on 8/23/2024 at 3:15 p.m., the ADM stated he was not available to complete the reporting process on 8/18/2024 due to personal circumstances and he was not aware the incident of abuse between Resident 1 and Resident 2 was not reported to the CDPH until 8/18/2024 at 11:55 p.m. The ADM stated the facility was in violation of their policy and Federal regulations for not reporting the alleged incident of abuse between Resident 1 and Resident 2 within two hours of the incident. A review of the facility's undated P/P, titled, "Abuse Prevention and Investigation," indicated the facility will not condone resident abuse by anyone including staff members, other residents, consultants, volunteers, staff, or other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals. The P/P indicated the facility will identify, correct and intervene in situations in which abuse, neglect, and or misappropriation of resident property is more likely to occur, this includes an analysis of features of the physical environment that may make abuse or neglect, more likely to occur, such as secluded areas of the facility (such as outside walkways), deployment of staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individuals residents' care needs. A review of the facility's P/P titled, "Abuse Reporting and Response," dated 8/1/2024, indicated it is the policy of the facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made. The facility failed to: 1. Ensure Resident 1 and Resident 2 were monitored during a smoking break while on the facility's patio by at least two facility staff, per the Director of Nursing (DON), in order to prevent a physical altercation between Resident 1 and Resident 2. 2. Report a physical altercation that occurred between Resident 1 and Resident 2 to the CDPH within two hours of the incident. On 8/18/2024 at approximately 8 a.m., facility staff witnessed Resident 2 elbow Resident 1 in her nose, however, the facility did not report the resident-to-resident altercation to the CDPH until 8/18/2024 at 11:55 p.m. (approximately 16 hours after the incident occurred). 3. Ensure their Policy and Procedure (P/P), titled "Abuse Reporting and Response" that indicated all alleged violations involving abuse are reported immediately but no later than two hours after allegation was made, and their P/P, titled, "Abuse Prevention and Investigation" that indicated will not condone resident abuse by anyone including other residents were followed. These failures resulted in: 1. Resident 1 sustaining a nose fracture (broken nose) and being transfer to a General Acute Care Hospital (GACH) where Resident 1 underwent a reduction of her nasal bones (a medical procedure that realigns [restores to a former position] broken nasal bones back into place), and compression with rightward pressure (a technique used to repair a nasal fracture) to repair/straighten her nasal deviation (occurs when the nasal septum [the boney structure that separates the nasal cavity into two sides, the right and left nostrils] is significantly displaced to one side, making one nasal air passage smaller than the other . 2. CDPH being unaware of the abuse incident and injury to Resident 1, which had the potential for a delay in CDPH's investigation and other abuse to occur and allegations of abuse to go unreported. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.