Other·September 20, 2023

F604 FCR §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). California Code Regulation (CCR) § 72315. Nursing Service – Patient Care (a) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. CCR § 72319. Nursing Service – Restraints and Postural Supports. (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. CCR § 72527. Patient 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 8/7/2023 at 12:30 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate two facility reported incidents regarding employee to patient abuse involving Patient 1 and Patient 2. As a result of the investigation, the California Department of Public Health (CDPH) determined that the facility failed to ensure Patient 1 and Patient 2 were free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) by failing to: 1. Protect Patient 1 from Certified Nursing Assistant 1 (CNA 1) when CNA 1 handled Patient 1 roughly and hit Patient 1's chest/shoulder area. 2. Protect Patient 2 from CNA 1 when CNA 1 tossed Patient 2's legs and pinned Patient 2 on the bed to prevent Patient 2 from moving. As a result of these failures, Patients 1 and 2 experienced physical abuse, and Patient 1 felt afraid and unsafe. a. During a review of Patient 1's Admission Record, the Admission Record indicated Patient 1 was an 86 year old female, and was admitted to facility on 4/9/2010, and readmitted on 3/24/2023 with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), hemiplegia (paralysis that affects one side of your body), hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), and heart failure (condition in which the heart cannot pump enough blood to all parts of the body). The Admission Record indicated Patient 1 stayed in Room A. During a review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/29/2023, the MDS indicated Patient 1 had moderately impaired cognition (poor decisions, required cuing and supervision) and was totally dependent on staff for transfers, dressing, and toilet use. During a review of the facility's Staff Assignment, dated 8/4/2023, from 11 pm to 7 am shift, the Staff Assignment indicated CNA 1 was assigned to care for Patients 1 and 2. During a Review of Patient 1's "Progress Note" dated 8/5/2023, the Progress Note indicated at 5:10 am, the charge nurse informed [Registered Nurse, RN 1] that Patient 1 alleged CNA 1 was being "very rough," and CNA 1 told Patient 1 to "shut up," "tossing her legs together," and hit Patient 1 on the chest/shoulder area. The notes indicated, RN 1 immediately got up and went into the Patient 1's room and witnessed CNA 1 being rough with another patient (Patient 2) who's room was located next to Patient 1's room. RN 1 witnessed CNA 1 tossing Patient 2's legs and CNA 1 putting CNA 1’s body weight on top Patient 2 to prevent Patient 2 from moving. The notes indicated, RN 1 told CNA 1 to stop what CNA 1 was doing, CNA 1 approached RN 1 very defensively, RN 1 asked CNA 1 to step outside of the Patient 2's room. 2. During a review of Patient 2's Admission Record, the Admission Record indicated Patient 2 was a 73 year old female, and was admitted to facility on 9/15/2022 and readmitted on 9/27/2022 with multiple diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), dementia (a group of thinking and social symptoms that interferes with daily functioning), and a history of cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain). The Admission Record indicated Patient 2 stayed in Room B. During a review of Patient 2's MDS, dated 5/28/2023, the MDS indicated Patient 2 had severe impaired cognition (ability to understand and process information) and required extensive assistance (patient involved in activity, staff provide weight-bearing support) from staff for transfers, dressing, toilet use, and personal hygiene. During a review of Patient 2's "SBAR (Situation Background Assessment and Recommendation, communication record between members of the health care team) Communication Form and Progress Note" dated 8/5/23, the form indicated RN 1 witnessed CNA 1 being rough with Patient 2 and RN 1 witnessed CNA 1 tossing Patient 2's legs and putting CNA 1's body weight on Patient 2 to prevent Patient 2 from moving. During a review of CNA 1's "Notice of Disciplinary Action" dated 8/5/23, the Notice of Disciplinary Action indicated CNA 1 was suspended for alleged abuse on 8/5/23. During a review of CNA 1's "Employee Separation Report" dated 8/7/23, the Employee Separation Report indicated CNA 1 was terminated on 8/7/2023 for violating facility rules and for misconduct and CNA 1 had prior disciplinary action. During an interview on 8/7/2023 at 12:36 pm, the Director of Nursing (DON) stated Patient 1 complained to Licensed Vocational Nurse (LVN) 1 that CNA 1 had been too rough when CNA 1 was changing Patient 1. The DON stated Patient 1 alleged CNA 1 had "tossed her legs" and had hit Patient 1 on her chest/shoulder area. The DON stated LVN 1 informed RN 1 who immediately went to Patient 1's room and saw CNA 1 with Patient 2. The DON stated RN 1 saw CNA 1 pinning Patient 2 down onto Patient 2's bed and tossing Patient 2's legs. The DON stated RN 1 called the DON right away and the DON instructed RN 1 to send CNA 1 home. During an interview on 8/7/2023 at 2:19 pm, Patient 1 stated CNA 1 came into Patient 1's room and jerked Patient 1's covers off. Patient 1 stated Patient 1 told CNA 1 that CNA 1 hurt Patient 1's legs when CNA 1 jerked off the covers. Patient 1 stated CNA 1 replied Patient 1 “was not hurt”. Patient 1 stated CNA 1 hit Patient 1 on Patient 1's left shoulder with CNA 1's open hand. Patient 1 stated LVN 1 heard CNA 1 and Patient 1 talking and came in Patient 1’s room to check on Patient 1. Patient 1 stated Patient 1 informed LVN 1 what CNA 1 had done and CNA 1 left and came back to Patient 1's room then CNA 1 pointed CNA 1's finger in Patient 1's face and said, "You are a liar." Patient 1 stated the incident made Patient 1 feel afraid to be alone. During an observation of Rooms A and B on 8/7/2023 at 2:30 pm, Rooms A and B were one big room and separated by a partial wall, Patient 1's bed was located on one side of the partial wall and Patient 2's bed was located on the other side. The two rooms shared one bathroom and the same hallway. During an interview on 8/8/2023 at 6:04 am, RN 1 stated on 5/5/2023 at 5:10 am, LVN 1 approached RN 1 and informed RN 1, CNA 1 was rough and hit Patient 1. RN 1 stated RN 1 immediately went to Patient 1's room and saw CNA 1 was with Patient 2, trying to remove Patient 2's adult incontinence brief. RN 1 stated CNA 1 held both of Patient 2's hands with one of CNA 1's hands. RN 1 stated Patient 2 was lifting Patient 2's legs up while CNA 1 changed Patient 2’s adult incontinence brief and CNA 1 slammed Patient 2's legs back down onto the bed. RN 1 stated CNA 1 was lying on top of Patient 2 and placing her bodyweight to make Patient 2 hold still while CNA 1 changed Patient 2's adult incontinence brief. RN 1 stated Patient 1 was in distress from the earlier incident that occurred with CNA 1. RN 1 stated what RN 1 witnessed CNA 1 doing to Patient 2 was [physical] abuse. RN 1 stated CNA 1 was being too rough and was pinning Patient 2 down on Patient 2's bed. RN 1 stated she did not witness CNA 1's mistreatment toward Patient 1 but Patient 1's allegation of mistreatment by CNA 1 was the same as what RN 1 witnessed CNA 1 did to Patient 2. During a telephone interview on 8/8/2023 at 8:48 am, LVN 1 stated on 5/5/23, early in the morning, LVN 1 heard Patient 1 yelling. LVN 1 stated she went in Patient 1's room to check what was going on. LVN 1 stated Patient 1 told her that CNA 1 was rough when changing Patient 1. LVN 1 stated CNA 1 was on the other side of the room getting things ready to help another patient. LVN 1 stated LVN 1 immediately went to RN 1 and told her of Patient 1's allegation against CNA 1. LVN 1 stated Patient was nice and was able to make Patient 1's needs known. LVN 1 stated about one month ago, a patient (no name recall) who was no longer at the facility had complained about CNA 1 being rude and the patient did not want CNA 1 taking care of them. During an interview on 8/9/2023 at 10:45 am, the DON stated RN 1 notified the DON on 5/5/23 around 5:20 am of the incident involving CNA 1, Patient 1, and Patient 2. The DON stated after the incident, Patient 1 was scared and got anxious at night. The DON stated the facility terminated CNA 1 and no one [staff] can treat a patient that way. During a review of the facility's Policy and Procedure (P&P) titled, "Abuse and Neglect Prohibition Policy," updated 6/30/2022, the P&P indicated it was the facility's policy to prohibit abuse that included physical abuse. As a result of the investigation, the CDPH determined that the facility failed to ensure Patient 1 and Patient 2 were free from physical abuse by failing to: a. Protect Patient 1 from CNA 1 when CNA 1 handled Patient 1 roughly and hit Patient 1's chest/shoulder area. b. Protect Patient 2 from CNA 1 when CNA 1 tossed Patient 2's legs and pinned Patient 2 on the bed to prevent Patient 2 from moving. As a result of these failures, Patients 1 and 2 experienced physical abuse, and Patient 1 felt afraid and unsafe. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety or security of Patient 1 and Patient 2.