Health inspection·December 31, 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 CCR§ 72523(a) 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 12/5/2024 the California Department of Health (CDPH) received a facility reported incident regarding verbal abuse of Resident 1 by Resident 2. On 12/10/2024 CDPH conducted an unannounced onsite investigation and determined the facility failed to ensure: a. Resident 1 was protected from verbal abuse by Resident 2. b. Resident 2, who showed repeated threatening and abusive behavior, was monitored for his verbal abuse, and verbal threats. c. Staff followed the facility’s policy and procedure (P&P) titled, “Change of Condition” revised 03/2021 indicating any changes in a resident’s condition will be thoroughly assessed and evaluated with physician notification for early clinical management. These failures resulted in on 12/5/2024 at 1 p.m. Resident 2 stated to Resident 1 “if you have a problem say it to my face” and threatening by saying “I will kill you.” A review of Resident 1’s Admission Record indicated Resident 1, a 70-year-old male, was admitted to the facility on 9/16/2024 with diagnoses including to schizophrenia (a mental illness that is characterized by disturbances in thought), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and chronic kidney diseases (progressive loss of kidney function). A review of Resident 1’s History and Physical (H&P) dated 9/20/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 9/22/2024, indicated Resident 1 needed maximal (helper provides more than half of the effort) assistance with toileting, lower body dressing, putting on and taking off footwear. The MDS indicated Resident 1 needed supervision with eating, oral hygiene, and personal hygiene. A review of Resident 2’s Admission Record indicated Resident 2, a 67-year-old male, was originally admitted to the facility on 2/26/2024 and re-admitted on 9/3/2024 with diagnoses including disseminated intravascular coagulation (a condition which small blood clots develop throughout the bloodstream), muscle weakness and acute kidney failure (a sudden loss of kidney function that occurs within a few hours or days). A review of Resident 2’s H&P dated 10/29/2024, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2’s MDS, dated 11/20/2024, indicated Resident 2 needed moderate assistance with showering, lower body dressing, putting on and taking off footwear. The MDS indicated Resident 2 needed supervision with transferring and changing positions from sitting to standing. During an interview on 12/10/2024 at 2:30 pm Restorative Nurse Assistant (RNA) 1 stated on 12/5/2024 at 1 pm, while in the dining room, Resident 1 was in his wheelchair eating lunch. RNA 1 stated Resident 2 went to Resident 1’s table and asked Resident 1 if he had a problem. RNA 1 stated Resident 1 said, “No, I am not saying anything”. RNA 1 stated Resident 2 said, “if you have a problem say it to my face.” RNA 1 stated Resident 2 verbally threatened to kill Resident 1. RNA 1 stated Resident 2 stated he did not care if he got kicked out from the facility. RNA 1 stated Resident 2 kept pushing forward and hitting his wheelchair against Resident 1’s wheelchair. During an interview on 12/10/2024 at 2:52 pm, Resident 1 stated he was seated in the dining room and Resident 2 approached him because Resident 2 was angry he was seated at a table and speaking with another resident (unknown) that Resident 2 did not like. Resident 1 stated Resident 2 rammed his wheelchair into his wheelchair and threatened to kill him. During a concurrent interview on 12/11/2024 at 9:02 am, Licensed Vocational Nurse (LVN) 1, the untitled Care Plan dated 12/5/2024 for Resident 2 was reviewed. The Care Plan Indicated Resident 2 told another resident “I will kill you”. The Care Plan indicated the goal for Resident 2 was not to make threats again. LVN 1 stated there was another Care Plan dated 11/17/2024 about Resident 2’s behavior threatening another resident (unknown) and a Change of Condition (COC- change in a resident’s health or functioning that can be short term or significant) form was not completed at that time. LVN 1 stated a COC is done to monitor the resident’s behavior. LVN 1 stated Resident 2’s behavior could have been monitored sooner if a COC was initiated on 11/17/2024 when Resident 2 threatened a resident (unknown). LVN 1 stated the Medical Doctor could have assessed Resident 2 sooner for any behavioral interventions. LVN 1 stated COC’s are initiated to monitor the resident’s behavior for improvement or decline. During an interview on 12/11/2024 at 4:29 pm, the Administrator (Adm) stated a similar incident happened one month ago between the Resident 1 and Resident 2. The Adm stated supervision is needed when Resident 1 and Resident 2 are in the dining room. The Adm stated Resident 1 and Resident 2 needed to be on opposite sides of the dining room to keep the distance between them both. The Adm stated Resident 2 was transferred to a General Acute Care Hospital (GACH) for behavior management related to the alleged verbal abuse on 12/5/2024. During a review of the facility’s P&P titled, “Abuse reporting and Prevention,” dated 1/2023, the P&P indicated “abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or mental anguish, or deprivation of an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing…Verbal abuse is the use of written oral, or gestured language that willfully used derogatory or disparaging terms regardless of their age, ability to comprehend or disability…Facility will monitor areas that have potential to lead to abusive situation, areas include …Residents with behaviors that may lead to abusive situations.” During a review of the facility’s P&P titled, “Change of Condition,” dated 3/2021, the P&P indicated, “it is the policy of this facility that any change in resident’s condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmission to acute hospitals.” The facility failed to ensure: a. Resident 1 was protected from verbal abuse by Resident 2. b. Resident 2, who showed repeated threatening and abusive behavior, was monitored for his verbal abuse, and verbal threats. c. Staff followed the facility’s policy and procedure (P&P) titled, “Change of Condition” revised 03/2021 indicating any changes in a resident’s condition will be thoroughly assessed and evaluated with physician notification for early clinical management. These failures resulted in on 12/5/2024 at 1 p.m. Resident 2 stated to Resident 1 “if you have a problem say it to my face” and threatening by saying “I will kill you.” These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.