Other·June 7, 2024

Code of Federal Regulations, Title 42, Section §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. California Code of Regulations, Title 22, Section 72315. Nursing Service – Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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 424/24 at 12:30 pm. the California Department of Public Health (CDPH, the Department) conducted an unannounced abbreviated standard survey visit for investigations regarding abuse and quality of care issues. As a result of the investigation, the Department determined the facility failed to protect Resident 3 from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation." As a result, on 4/24/2024 at 9 pm, Resident 4 threw a trash bin at Resident 3 (Resident 4's roommate) while Resident 3 was sleeping in Resident 3's bed. Resident 3 sustained corneal abrasion (scratch or cut on the white portion of the eye) and acute iritis (inflammation of the colored portion of the eye) to Resident 3's right eye. Resident 3 was transferred to General Acute Care Hospital (GACH) 1 on 4/25/2024 at 12:50 am for evaluation and treatment of injuries. Resident 3 received antibiotic (medication used to prevent and treat infections) eye ointment to be applied to both eyes every eight hours. a. A review of Resident 3's Face Sheet (FS), indicated the facility admitted Resident 3, a 101-year-old male to the facility on 2/16/2024, with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/16/2024, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/23/2024, indicated Resident 3 was able to communicate verbally and required partial/moderate assistance (helper did less than the effort) from staff for oral hygiene, toileting hygiene, and walking 10 feet. A review of Resident 3's Licensed Personnel Progress Notes (LPPN), dated 4/24/2024, timed at 11:58 pm, indicated on 4/24/2024 at approximately 9 pm, Certified Nursing Assistant (CNA) 8 reported to the Registered Nurse Supervisor (RNS) that CNA 8 saw Resident 4 throw a trash bin at Resident 3. The LPPN indicated, CNA 8 was walking towards the soiled linen room when CNA 8 saw Resident 4 in the wheelchair go inside Resident 3's and Resident 4's room, located across the hall from the soiled linen room. The LPPN indicated, when CNA 8 opened the soiled linen room door, CNA 8 looked back toward Resident 3's and Resident 4's room and saw Resident 4 standing at the foot of Resident 3's bed. The LPPN indicated, Resident 4 then picked up the trash bin from the floor at the foot of Resident 3's bed and suddenly threw the trash bin at Resident 3 who was sleeping in Resident 3’s bed. The LPPN indicated, when CNA 8 saw Resident 4 pick up the trash bin, CNA 8 did not realize Resident 4 would throw the trash bin at Resident 3. The LPPN indicated, Resident 3 "sustained bloodshot [when white of eye becomes red] to [the] right eye" with swelling, scratches below the right eye, "bump" on the forehead, and scratch to the left inner eyebrow. A review of Resident 3's LPPN, dated 4/25/2024, timed at 1 am, the LPPN indicated, the facility transferred Resident 3 to GACH 1 on 4/25/2024 at 12:50 am. A review of Resident 3's GACH 1 Emergency Room Patient Visit Information (ER PVI), dated 4/25/2024, untimed, indicated Resident 3 received attention in GACH 1 ER for corneal abrasion and acute iritis. The ER PVI indicated, GACH 1 ER Physician prescribed Resident 3 an antibiotic eye ointment to be applied to both eyes every eight hours. b. A review of Resident 4's FS, indicated the facility admitted Resident 4, a 60-year-old male, to the facility on 3/15/2024, with diagnoses that included encephalopathy (brain disease, damage, or malfunction), schizophrenia, and mood disorder. A review of Resident 4's Care Plan (CP) titled, "Resident care plan for Schizophrenia Disorder," dated 3/15/2024 indicated, Resident 4 had schizophrenia manifested by throwing items at staff for no reason. The CP goal indicated, Resident 4 would have less episodes of throwing items at staff for no reason. The CP interventions included for staff to eliminate stressors and triggers for agitation and create a safe and calm environment. A review of Resident 4's H&P, dated 3/18/2024, indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4's MDS, dated 3/19/2024 indicated, Resident 4 was able to communicate verbally, and required supervision or touching assistance (helper provided verbal cues and/or touching/steadying assistance as resident completed activity) from staff with standing from a sitting position and getting in and out of bed or a chair/wheelchair, and required setup or clean-up assistance (helper set up or cleaned up and resident completed activity) to wheel the wheelchair 50 feet with two turns. A review of Resident 4's LPPN, dated 4/24/2024, timed at 11:45 pm, indicated on 4/24/2024 at approximately 9 pm, CNA 8 was walking towards the soiled linen room when CNA 8 saw Resident 4 in the wheelchair going inside Resident 3's and Resident 4's room. The LPPN indicated, when CNA 8 opened the soiled linen room door, CNA 8 looked back toward Resident 3's and Resident 4's room and saw Resident 4 standing at the foot of Resident 3's bed. The LPPN indicated, Resident 4 then picked up the trash bin from the floor at the foot of Resident 3's bed and suddenly threw the trash bin at Resident 3 who was sleeping in Resident 3’s bed. The LPPN indicated, Licensed Vocational Nurse (LVN) 9 notified Resident 4's psychiatrist on 4/24/2024 at 9:49 pm. During an observation on 4/25/2024 at 1:35 pm and 4/26/2024 at 12:35 pm, Resident 3 was observed with a dried red small cut by Resident 3's left eyebrow. Resident 3's right eye was smaller than Resident 3's left eye, the white of Resident 3's right eye was red, and Resident 3's right eyelid and area under Resident 3's right eye were swollen and purplish in color. During an interview on 4/25/2024 at 2:03 pm RNS stated on 4/24/2024 at approximately 9 pm, LVN 9 informed the RNS that Resident 4 threw a trash bin at Resident 3. The RNS stated Resident 3 and Resident 4 were roommates. The RNS stated the RNS found Resident 3 sitting in a chair in the hallway with a staff (unidentified). The RNS stated the RNS assessed Resident 3 and Resident 3's right eye was bloodshot with swelling. The RNS stated Resident 3 had two cuts under Resident 3's right eye and a cut by the right eyebrow. The RNS stated the RNS asked Resident 4 what happened and Resident 4 stated, "I don't know." During an interview on 4/25/2024 at 2:21 pm CNA 8 stated on 4/24/2024 at 9 pm, CNA 8 stated CNA 8 was walking to the soiled linen room and saw Resident 4 in the wheelchair. CNA 8 stated Resident 4 wheeled Resident 4's wheelchair inside Resident 3's and Resident 4's room. CNA 8 stated CNA 8 thought Resident 4 was going to bed because that was what Resident 4 usually did at that time of the night. CNA 8 stated when CNA 8 opened the door to the soiled linen room, CNA 8 looked back and saw Resident 4 standing up. CNA 8 stated Resident 4 suddenly picked up the trash bin from the floor by the foot of Resident 3's bed and threw the trash bin at Resident 3 who was sleeping in Resident 3’s bed. CNA 8 stated CNA 8 yelled at Resident 4 to stop as CNA 8 ran inside Resident 3's and Resident 4's room. CNA 8 stated as CNA 8 was running to the room, Resident 4 sat back down in Resident 4's wheelchair. CNA 8 stated Resident 3 stayed in the middle bed and Resident 4 stayed in the bed by the window. CNA 8 stated the trash bin was on the floor by the foot of Resident 3's bed where Resident 4 had to pass through to get to Resident 4's bed. During a review of the facility's P&P titled, "Abuse, Neglect and Exploitation," undated, the P&P indicated, each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated, residents must not be subjected to abuse by anyone, including, but not limited to other residents. As a result of the investigation, the Department determined the facility failed to protect Resident 3 from physical abuse as indicated in the facility's P&P titled, "Abuse, Neglect and Exploitation." As a result, on 4/24/2024 at 9 pm, Resident 4 threw a trash bin at Resident 3 while Resident 3 was sleeping in Resident 3's bed. Resident 3 sustained corneal abrasion and acute iritis to Resident 3's right eye. Resident 3 was transferred to GACH 1 on 4/25/2024 at 12:50 am for evaluation and treatment of injuries. Resident 3 received antibiotic eye ointment to be applied to both eyes every eight hours. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 3.