Health inspection·January 29, 2025

California Code of Regulations, Title 22,    § 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.  § 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.    Code of Federal Regulations, Title 42    F600 Freedom from Abuse, Neglect, and Exploitation   §483.12 Freedom from Abuse, Neglect, and Exploitation The Patient has the right to be free from abuse, neglect, misappropriation of Patient 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 Patient’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;    On 12/27/2024 at 9:55 AM, an unannounced visit was made by the California Department of Public Health (CDPH) to the facility to conduct an investigation for facility reported incidents (FRI) patient to patient abuse.  As a result of the investigation, CDPH determined that the facility failed to protect the patient’s rights to be free from physical abuse for Patients 7, 6, and 4 by failing to:   1. Protect Patient 7 from Patient 3 on 12/14/2024, while Patient 3 was on “line of sight” (LOS) supervision. As a result, Patient 3 hit Patient 7 on right side of the back of the head and left side of the chest with a right-hand closed fist that scratched Patient 7’s left forearm.  2. Protect Patient 6 from Patient 2 on 12/15/2024, after Patient 2 had a previous incident of wandering into Patient 6’s and other Patient rooms. As a result, Patient 2 went into Patient 6’s room and hit Patient 6’s left ear while she was sleeping in her bed.  3. Protect Patient 4 from Patient 1, after Patient 1 had an episode of agitation with staff and prior altercation with Patient 5 on 12/19/2024. As a result, Patient 1 hit Patient 4 on the face and back of the head.  These deficient practices resulted in Patient 7, 6, and 4 to experience physical abuse.  Findings:  1. A review of Patient 7’s Admission Record [AR] indicated a 46 year old, male patient, admitted to the facility on 3/3/2023 with diagnoses including schizoaffective disorder, schizophrenia, and major depressive disorder.  A review of Patient 7’s Minimum Data Set (MDS, an assessment and screen tool) dated 9/13/2024, the MDS indicated Patient 7 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience and the senses).  A review of Patient 3’s AR, the AR indicated a 33 year old, male patient, admitted to the facility on 2/16/2023 with diagnoses including hyperlipidemia, mild intellectual disabilities, and extrapyramidal and movement disorder.  A review of Patient 3’s MDS dated 11/24/2024, the MDS indicated Patient 3 had moderately impaired cognition.  A review of Patient 3’s Order Summary Report dated 8/27/2024, the Report indicated a physician order to place Patient 3 on LOS from 7 AM to 3 PM, 3 PM to 11 PM, and every 15 minutes monitoring on 11 PM to 7 AM shift due to attempt to hit another peer.  A review of Patient 3’s Nursing Progress Notes dated 12/14/2024 timed at 10:16 PM, The Notes indicated at 5:30 PM, Patient 3 saw Patient 7 standing at the corner of the Nursing Station, stopped walking and made an “inappropriate facility gesture” with Patient 7. The Note indicated Patient 3’s LOS verbally redirected Patient 3 to walk away and Patient did not comply. The note indicated Patient 3 walked closer to Patient 7 and hit Patient 7 on right side of the back of the head and left side of the chest with a right-hand closed fist that scratched Patient 7’s left forearm. The note indicated a “Code Yellow” was called and both Patients were separated.  During an interview with the Social Worker on 12/27/2024 at 10:37 AM, the SW stated Patient 3 was fixated on Patient 7 and whenever Patient 3 sees Patient 7, Patient 3?assumes Patient 7 was making faces at him and will hit him. The SW stated Patient 3 was given a 30-day notice (discharge placement) to find placement at a higher level of care. The SW could not recall when the 30-day notice was given to Patient 3.  During a concurrent interview and record review of Patient 3’s 30-day notice dated 10/10/2024 on 12/27/2024 at 11:09 AM, the Program Director (PD) stated the Patient was given the notice because he continued to have physical aggression towards others and continued to be on the LOS. The PD stated it was discussed with the facility’s Interdisciplinary Team (IDT) that Patient 3 was a danger to himself and others and needed a higher level of care. The PD stated there was a delay with Patient 3’s 30-day notice because the facility tried to exhaust many options such as increasing Patient 3’s medications and care plan meetings. The PD stated, in addition they are still unable to find him placement and waiting for placement in a higher level of care at this time. The PD stated it was important that Patient 3 was not in contact with other Patients at this time for Patient safety.  During a concurrent interview and record review of Patient 3’s Progress Notes from 10/2024 to 12/2024 on 12/27/2024 at 11:35 AM, the SW could not find documented evidence of any note that indicated the Patient’s 30-day notice follow up.  2. A review of Patient 6’s AR indicated a 51 year old, female patient admitted to the facility on 3/12/2024 with diagnoses including schizoaffective disorder, type 2 diabetes mellitus, and insomnia.  A review of Patient 6’s MDS dated 9/21/2024, the MDS indicated Patient 6’s cognition was intact.  A review of Patient 2’s AR indicated a 49 year old, male patient, admitted to the facility on 2/14/2024 with diagnoses including schizoaffective disorder, extrapyramidal and movement disorder and type 2 diabetes mellitus.  A review of Patient 2’s MDS dated 11/19/2024, the MDS indicated Patient 2 had severely impaired cognition.  A review of Patient 2’s Late Entry Physician’s Order Noted dated 11/24/2024 timed at 16:57, the Physician Order indicated the physician received a phone call that Patient 2 was more irritable, entering people’s rooms and punching them.  A review of Patient 2’s Care Plan dated 12/7/2024, the Care Plan indicated the Patient entered a female Patient’s room and moved all her belongings, leaving juice and other items. The care plan indicated an intervention to encourage Patient 2 to refrain from entering into peers' rooms and refrain from taking things that do not belong to them.  A review of Patient 2’s Progress Notes dated 12/15/2024 timed at 11:37 PM, the Notes indicated at 7:05 PM, Patient 2 went into Patient 6’s room and hit Patient 6’s left ear while she was lying on her bed sleeping. The note indicated Patient 6 woke up and followed Patient 2 to the Nursing Station. The Note indicated both Patients were separated with no injuries. The Note indicated Patient 2 was placed on LOS monitoring for Patient safety.  During an interview with Patient 6 on 12/27/2024 at 2:07 PM, Patient 6 stated she woke up to Patient 2 hitting her on the head. Patient 6 stated Patient 2 started going into her room a week prior and “he would come into our room and drop off clothes saying it was his room.”  Patient 6 stated she screamed for help, but no one came to her room. Patient 6 stated she followed Patient 2 out of her room and went to the Nursing Station to report what happened. Patient 6 stated it was the first time Patient 2 hit her. Patient 6 stated Patient 2 had the tendency to go into other rooms, but would specifically go into her room to hide stuff under her bed.  During a telephone interview with Certified Nursing Assistant (CNA) 1 on 12/30/2024 at 11:46 AM, CNA 1 stated that on 12/15/2024. she heard Patient 6 say “Get out of my room.” CNA 1 stated she stood up when she heard Patient 6 and followed the Patients. CNA 1 stated Patient 6 said out loud to the staff “He keeps coming into my room.” CNA 1 stated before the incident she saw Patient 2 “Going by the area (Patient 6’s room) all morning.”  During a telephone interview with licensed vocational nurse (LVN) 1 on 12/30/2024 at 12:10 PM, LVN 1 stated Patient 2 had a behavior or wandering into other Patient rooms a week prior the abuse incident of Patient 6, on 12/15/2024. LVN 1 stated male Patients were not allowed to go into female Patient rooms. LVN 1 stated in Patient 2’s last few days at the facility he was going into other Patients room and he was looking for something in the rooms. LVN 1 stated Patient 2 was monitored closely by staff, was redirected, but not compliant when redirected. LVN 1 stated within Patient 2’s last few weeks at the facility, his behaviors had changed.  During a telephone interview with LVN 2 on 12/30/2024 at 12:33 PM, LVN 2 stated Patient 2 was convinced Patient 6’s room was his room. LVN 2 stated she saw Patient 2 go into Patient 6’s room more than once a few days before. LVN 2 stated it would be best to place Patient 2 on LOS and to monitor where Patient was so that the incident doesn’t happen again.  During a telephone interview with the Program Counselor (PC) 1 on 12/30/2024 at 12:55 PM, PC 1 stated it was important to monitor Patient 2 because of his behavior of going into Patient rooms so that “we can stop situations like this, be more alert and find different strategies to help Patient and to utilize coping skills some things could have been done to deescalate the situation.”  During an interview with the Administrator (ADM) on 12/30/2024 at 4:59 PM, the ADM stated male Patients are not allowed in female Patients rooms, if Patient 2 was monitored more often especially with going into Patients rooms, staff would’ve been able to stop him from going into Patient 6’s room.  3. A review of Patient 5’s AR indicated a 58 year old, male patient, admitted to the facility on 9/19/2019 with diagnoses including schizoaffective disorder, psoriasis, and hyperlipidemia.  A review of Patient 5’s MDS dated 11/6/2024, the MDS indicated Patient 5 had moderately impaired cognition.  A review of Patient 4’s AR indicated a 44 year old, female patient, admitted to the facility on 9/16/2021 with diagnoses including schizoaffective disorder, extrapyramidal and movement disorder and hypothyroidism.  A review of Patient 4’s MDS dated 9/25/2024, the MDS indicated Patient 4 had severely impaired cognition.  A review of Patient 4’s Nursing Progress Notes dated 12/19/2024 timed at 10:08 PM, the Notes indicated at 6:55 PM, Patient 4 reported Patient 1 approached her and began to hit her with a closed right fist to both sides of her face. The Note indicated Patient 4 put her head down and got hit in the back of her head and she screamed for Patient 1 to stop. The note indicated staff ran to assist and separate/stop Patient 1 from continuing to hit Patient 4. The note indicated no injures and ice packs to be applied to Patient 4’s face to prevent swelling. The Note indicated 72- hour neuro-check and every 15 minute monitoring was ordered for Patient safety.  A review of Patient 1’s AR indicated a 58 year old, male patient, admitted to the facility on 3/21/2024 with diagnoses including paranoid schizophrenia, schizophrenia, and hypertension.  A review of Patient 1’s MDS dated 9/24/2024, the MDS indicated Patient 1’s cognition was intact.  A review of Patient 1’s Order Summary dated 12/19/2024, the Report indicated a physician order to place Patient on LOS monitoring for safety starting at 7:00 PM post hitting peer.  A review of Patient 1’s Care plans dated 12/19/2024, the Care Plans indicated the following incidents:  a. Physical aggression towards peer- Patient 1 hit Patient 4 on the face and back of the head  b. Physical aggression towards peer- Patient 1 punched Patient 5 on the chest one time  c. Patient became agitated, got up, silverware and walked towards female CNA after reminding him about his fluid restriction order  A review of Patient 1’s Nursing Progress Notes dated 12/19/2024, the Notes indicated the following:  a. On 12/19/2024 timed at 12:18 PM the note indicated at approximately 8:35 AM, Patient 1 was in front of Nursing Station 1 waiting for medications with Patient 5. The note indicated both Patients began to argue and Patient 1 walked away. The note indicated Patient 1 went back to Patient 5 and punched him in the chest causing Patient 5 to fall to the floor. The note indicated staff immediately intervened and there were no apparent injuries.  b. On 12/19/2024 timed at 12:10 PM the note indicated at approximately 12:10 PM during meal time in the dining room, Patient 1 was easily agitated after reeducation and reminder of his fluid restriction order by a female CNA. The note indicated in the middle Patient 1 eating his lunch, Patient stood up, took his fork and walked towards the female CNA. The note indicated male counselors intervened and Patient 1 was redirected.  c. On 12/19/2024 timed at 11:30 PM, the note indicated Patient 1 was walking and Patient 4 was sitting on the bench and he began to hit her with his right closed fist and made contact to both sides of her face as well as the back side of her head. The note indicated the mental health worker (MHW) implemented pro-act to put Patient 1 in a moving restraint for 30 seconds from 6:55:30 to 6:56 PM and 2- man seated restraint for 1 minute from 6:56 to 6:57 PM until Patient no longer danger to others. The note indicated Patient 4 was moved from the area and was seated on the bench down the hallway for safety. The note indicated Patient 1 heard voices telling him to hit Patient 4. The note indicated body check was done for both Patients and no injuries were noted.  During an interview with Patient 4 on 12/27/2024 at 2:12 PM, Patient 2 stated she was sitting on a bench when Patient 1 hit her, she could not recall if Patient 1 said anything to her or if she was hit before.  During an interview with PC 2 on 12/27/2024 at 3 PM, PC 2 stated he was working on his documentation when the incident between Patient 1 and 4 occurred. PC 2 stated MHW 1 was present at the time and Patient 1 was on every 15 minute monitoring, not LOS.  During a telephone interview with MHW 1 on 12/30/24 at 12:44 PM, MHW 1 stated he was assigned at hall monitor and was doing his rounds and saw Patient 1 hitting Patient 4. MHW 1 stated he was there when he heard the yell and he assisted with another staff to separate Patient 1 from hitting Patient 4. MHW 1 stated he did not see any injuries on both Patients.  During a telephone interview with PC 1 on 12/30/2024 at 12:55 PM, PC 1 stated she heard Patient 1 was aggressive, and that there was “aggression prior to incident, he was aggressive towards staff.” PC 1 stated she didn’t know any details of incident prior, but that Patient 1 should have been placed on LOS prior to incident with Patient 4 to have more monitoring of Patient.  During an interview with the ADM on 12/30/2024 at 4:48 PM, the ADM stated Patient 1 was not at facility and she would not accept him if he returns. The ADM stated Patient 1 should have been put on LOS earlier, and that this Patient should always have to be in line of sight because he was an assaultive Patient. The ADM stated had Patient 1 been on LOS after the 2nd incident on 12/19/2024 with the female CNA, the 3rd incident with Patient 4 could have been avoided. The ADM stated when a Patient is on LOS, the staff have to be within line of sight of Patient, there is no measurable distance, but the staff should be near Patient and always have eyes on the Patient. The ADM stated LOS was more frequent monitoring than every 15 minutes monitoring.  During