Health inspection·July 12, 2023

F600 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.

F658 483.21 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— (i) Meet professional standards of quality An unannounced visit was conducted by the California Department of Public Health (CDPH) on 5/25/23 at 9:30 AM to investigate a facility reported incident regarding patient – to – patient altercation and a complaint regarding patient’s death resulting from the patient- to- patient altercation. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure Patient 1 was free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish). Patient 2, who had behavioral issues, hit Patient 1 on the face and head on 5/20/23 in Patient 1 and 2’s room. 2. Identify, assess, and implement interventions to address Patient 2’s cognitive (the ability to clearly think, learn, and remember) impairment and behavior of wandering to other patient’s rooms and going through other patient’s belongings, in accordance with the facility’s Abuse Prohibition Policy, which resulted to Patient 2 hitting Patient 1 on the face. 3. Protect Patient 1 when Patient 3 reported to Licensed Vocational Nurse 2 (LVN 2) about Patient 2’s behavioral issues of wandering to other patient’s rooms and going through other patient’s belongings in accordance with the facility’s Abuse Prohibition Policy. Patient 3 requested for Patient 2 to be transferred to another room on several occasions prior to 5/20/23. Patients 1, 2, and 3 remained in the same room up to 5/20/23. 4. Provide treatment and services for Patient 1, after being hit on the face and head, in accordance with current professional standard of practice that includes conducting a neurological assessment on 5/20/23 in accordance with the facility’s Neurological Assessment policy. 5. Identify changes in Patient 1’s neurological status when the patient refused neurological assessment on 5/20/23 at 4:30 AM and 5 AM and to document Patient 1’s reasons for refusing assessment and implement alternative interventions after the patient refused in accordance with the facility’s policy. 6. Obtain a Physician order for Patient 1 to have a Neurological Assessment in accordance with the facility’s Neurological Assessment policy. These failures resulted in Patient 1 to being subjected to physical abuse. Patient 1 was found unconscious on 5/20/23 at 7 AM, six (6) hours and 30 minutes after the patient was hit on the face and head by Patient 2. Patient 1 was transferred to the General Acute Care Hospital (GACH) via 911 (a number to contact emergency services) was called. According to GACH records, Patient 1 sustained a large right subdural hematoma (collection of blood outside the brain) measuring up to 3.7 centimeters (cm, unit of measurement) and was comatose (state of deep unconsciousness for a prolonged period) upon arrival to the GACH. Patient 1 died on 5/22/23 in the GACH with diagnoses that included large subdural hemorrhage (a pool of blood between the brain and its outermost covering), neurogenic shock (a life-threatening medical condition in which there is insufficient blood flow throughout the body), and brain death (permanent, irreversible, and complete loss of brain function). This deficient practice also placed Patient 3 and other patients in the facility at risk of being physically abused by Patient 2. Patient 1’s Admission Record indicated the patient was a 67- year- old- male who was initially admitted to the facility on 3/28/22 and readmitted on 5/16/23. Patient 1’s diagnoses included end stage renal disease (a medical condition in which a patient’s kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life), dependence on renal dialysis, generalized muscle weakness and abnormalities of gait and mobility. A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 4/14/23, indicated Patient 1 was independent with cognitive (the ability to clearly think, learn, and remember) skills for daily decision making. Patient 1 was totally dependent (full staff performance) with one person for bed mobility, transfer, dressing, toilet use and personal hygiene. Patient 2’s Admission Record indicated the patient was an 85- year- old- male who was initially admitted to the facility on 12/30/21 and readmitted on 10/17/22. Patient 2’s diagnoses included dementia, without behavioral disturbance, psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), mood disturbance (feelings of distress or sadness) and anxiety (feeling of fear, dread, and uneasiness). A review of Patient 2’s MDS, dated 4/5/23, indicated Patient 2 was severely impaired with cognitive skills for daily decision making. Patient 2 was totally dependent with one- person assist for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Patient 3’s Admission Record indicated the patient was a 66- year- old- male who was admitted to the facility on 7/21/20. Patient 3’s diagnoses included right above knee amputation and muscle weakness. Patient 3’s MDS, dated 4/5/23, indicated Patient 3 had an intact cognitive skill for daily decision making. Patient 3 required limited assistance (staff provide guided maneuvering) with one-person assist for bed mobility, transfer, dressing, and toilet use and personal hygiene. A review of Patient 1’s Nurses’ Note, dated 5/20/23 at 1:30 AM, indicated Patient 1 was in bed when Patient 2 came up to him and tried to take his jacket. Patient 1 refused so Patient 2 hit him on the left side of his face. Licensed Vocational Nurse 1 (LVN 1) indicated a neurological check (assess an individual’s neurological functions, motor and sensory response, and level of consciousness) was started. A review of Patient 1’s Neurological Evaluation Flowsheet indicated a neurological assessment was completed for Patient 1 on 5/20/23 at 1:30 AM, 1:45 AM, 2AM, 2:15 AM, 2:30 AM, 2:45 AM, 3AM, 3:15 AM, 3:30 AM, and 4 AM. At 4:30 AM and 5 AM, it was documented that Patient 1 refused the neurological assessment. The Neurological Evaluation Flowsheets did not include an assessment for patterns of speech, speech clarity, gag reflex, facial drooping, and GCS, as indicated on the facility Neurological assessment policy revised 10/2010 A review of Patient 2’s Nurses’ Note, dated 5/20/23 entered at 4:06 AM, indicated Patient 2 went up to Patient 1, and tried to take his jacket but Patient 1 resisted so Patient 2 hit him on the left side of his face. A review of Patient 1’s Nurses’ Note, dated 5/20/23, timed at 8:55 AM, indicated Registered Nurse 1 (RN 1) found Patient 1 unresponsive with oxygen saturation at 87% at 7AM. 911 was called and Patient 1 was transferred to the GACH. During a concurrent interview with Licensed Vocational Nurse 5 (LVN 5) and record review of the Neurological Evaluation Flowsheet on 5/25/23 at 3:15 PM, LVN 5 verified that the Neurological Evaluation Flowsheet for Patient 1 indicated that there was no neurological assessment conducted on 5/20/23 from 5:30 AM to 6:30 AM. LVN 5 stated that it should have been done every 30 mins as indicated on the flowsheet. LVN 5 added it was important to follow the instructions on the frequency of assessment as indicated on the Neurological Evaluation Flowsheet form to ensure whether the patient needs emergency medical treatment after a head injury. During a concurrent interview with RN 1 and record review of Patient 1’s Neurological Evaluation Flowsheet on 5/25/23 at 4:10 PM, RN 1 validated that Patient 1 did not have a neurological assessment from 5:30 AM to 6:30 AM. The last vital signs obtained for Patient 1 were at 4AM. RN 1 stated it was important to check and follow time intervals indicated in the Neurological Evaluation Flowsheet to assess if there was a change in Patient 1’s condition. RN1 stated a neurological assessment must be conducted to monitor any head injury, bleeding, or swelling to the brain or any change in a patient’s level of consciousness. During a concurrent interview with RN 2 and review of Patient 2’s medical records on 5/25/23 at 5:20 PM, RN 2 verified Patient 2’s behavior of wandering to other patient rooms and going through other patient belongings but there was no behavior monitoring and interventions done to address the behavior prior to the altercation between Patient 1 and 2 on 5/20/23. RN 2 stated Patient 2 should have been moved out of the room and be placed in a “single” room after the altercation, to protect Patient 1 and prevent another patient- to- patient altercation. During the same interview with RN 2 and record review of Patient 1’s Order Summary Report on 5/25/23 at 5:20 PM, RN 2 verified that there was no order for a neurological assessment to be conducted for Patient 1. RN 2 stated a physician order should have been obtained based on the facility policy on Neurological Assessment. RN 2 also verified that Patient 1 refused the neurological assessment on 5/20/23 at 4:30 AM and 5AM as indicated on the flowsheet. RN 2 stated LVN 1 should have notified the physician when Patient 1 refused the assessment. During an interview with the DSD on 5/26/23, at 10:58 AM, the DSD stated neurological assessment or “neuro check” was conducted to assess if patients were alert and oriented after a head injury. The DSD stated neuro checks should include assessing patient’s pattern of speech, speech clarity, gag reflex, facial drooping, and use of GCS, which are in accordance with the facility policy. The DSD stated when a patient refuses a neuro check, intervention included was to call for another nurse to conduct the assessment. The DSD stated the reason for patient’s refusal and any additional interventions taken by the staff should be documented on the patient’s clinical record. During an interview on 5/26/23, at 11:07 AM, the DSD stated, Patient 2 was very confused and would sometimes enter other patients’ rooms and needs to be redirected back to his room. During an interview on 5/26/23, at 11:23 AM, LVN 4 stated on 5/20/23 at 7 AM, LVN 4 found Patient 1 unresponsive. LVN 4 stated Patient 1 did not regain consciousness and was transported via 911 to the GACH. LVN 4 stated when a patient refuses neuro checks, the LVN should document the refusal and implement other interventions such as explaining to the patient why the assessment needs to be conducted and to have another nurse assist and perform the neuro check. During a concurrent interview with RN 2 and record review of Patient 1’s Neurological Evaluation Flowsheet on 5/26/23, at 1:14 PM, RN2 stated, Patient 1 was on neurochecks due to an abuse allegation of being hit on the face by Patient 2. RN2 stated a neuro check was done using the Neurological Evaluation Flowsheet to assess level of consciousness and orientation of the patient. RN2 stated there was no indication on the flowsheet to assess facial drooping. RN2 stated the neurological assessment performed was only based on the specific information on the flowsheet. RN2 stated the Neurological Evaluation Flowsheet did not indicate other assessments such as gag reflex and utilization of the GCS, so they were not done. During a concurrent interview with RN 2 and record review of Patient 1’s Nurses Progress Notes on 5/26/23, at 1:29 PM, RN2 stated there were no interventions done and documented to address Patient 1’s refusal for neuro check. During a telephone interview on 5/26/23 at 3:25 PM, LVN 1 stated that she started Patient 1’s neuro check after it was reported that Patient 1 was hit on the face. LVN 1 stated, she checked Patient 1’s pupil reaction, hand grip, and if able to respond to questions. LVN 1 further stated, “Patient 1 refused neuro check because he asked me to stop and was getting tired and sleepy.” During the same interview with LVN 1, LVN 1 stated, on 5/20/23 at 1:30 AM , Certified Nurse Assistant 3 (CNA 3) told her Patient 2 hit Patient 1. LVN 1 stated, she went into Patient 1’s room and was told by Patient 1 that Patient 2 hit him on the head and face with Patient 2’s right hand. During an interview on 5/26/23, at 3:29 PM, Patient 4 (witness of Patient 2’s aggressive behavior) stated on 5/15/23 (five days prior to the altercation between Patient 1 and 2) Patient 2 had previously pushed Patient 3 with clenched hands. Patient 4 stated Patient 3 grabbed his grabber reacher (a tool that works as an extension of the arm) to block Patient 2. Patient 4 stated, he and Patient 3 were aware Patient 2 was unstable and “could snap any time.” Patient 4 stated Patient 3 notified the facility staff that Patient 2 was unstable, but facility staff did not listen and did not do anything. During an interview on 5/26/23, at 4:28 PM, CNA 1 stated Patient 1 had redness on the left side of his face by the temple (located on the side of the head behind the eye between the forehead and the ear) area. CNA 1 stated on 5/20/23, approximately at 5:30 AM, CNA1 noticed “something was off” with Patient 1 and that Patient 1 was in a deep sleep. CNA1 stated she patted Patient 1 on his chest but was not arousable, so she called LVN1 who assessed Patient 1. CNA1 stated Patient 1 continued to have redness on the left side of his face. CNA1 stated LVN1 was aware of Patient 1’s facial redness. During an interview on 5/26/23, at 6:08 PM, LVN3 stated Patient 2 was confused and required supervision. LVN3 stated Patient 2 would enter other patients’ rooms and needed to be redirected back to his room. LVN3 stated on 5/18/23, two days prior to the altercation between Patients 1 and 2, Patient 2 entered an unnamed patient’s room trying to take the patients wheelchair. LVN3 stated Patient 3