Other·September 23, 2022

F603 §483.12 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. § 72319. Nursing Service - Restraints and Postural Supports. (a) Seclusion, which is defined as the placement of a patient alone in a room, shall not be employed. § 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. T22 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. On 8/12/2022 at 10:27 am, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding infection control. The facility failed to ensure Patients 1 and 2 were free from involuntary seclusion (separation of a patient from other patients or from her/his room or confinement to her/his room with or without roommates against the patient’s will, or the will of the patient representative). by failing to ensure: 1. Certified Nursing Assistant (CNA 1) did not leave Patients 1 and 2 inside their room involuntarily secluded without staff present in the Red Cohort [isolation rea, area only for patients who have laboratory confirmed Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) with or without symptoms, regardless of vaccination status]. 2. CNA 1 closed Patient 1’s and 2’s door and tied the door handle with a clear trash bag to the handrail from the outside of the door to prevent the patients’ egress (exit) from the room while CNA 1 left his assigned area. These deficient practices violated Patients 1’s and 2’s rights and had the potential for Patients 1 and 2 to further experience incidents of involuntary seclusion that could lead to serious injury, and serious harm. 1. A review of Patient 1’s Admission Record indicated the facility admitted an eighty-seven-year-old-female patient on 2/7/2022 with diagnoses that included dementia (a group of symptoms affecting memory, thinking and social abilities) with behavioral disturbance (inappropriate behavior), muscle weakness and age-related physical debility (frailty). A review of Patient 1’s History and Physical dated 2/8/2022, indicated the patient could make needs known but could not make medical decisions. A review of Patient 1’s Medication Administration Record, initiated on 2/8/2022, indicated for staff to monitor Patient 1 for episodes of attempted wandering (walk or move in an easy, casual, or aimless way). A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/13/2022, indicated Patient 1 was severely impaired in cognitive skills (ability to make decisions). The MDS indicated Patient 1 had behavior of wandering and required supervision (oversight, encouragement, or cueing) with all activities of daily livings (ADLs) such as with walking and toileting. A review of Patient 1’s Care Plan for Fall, dated 8/9/2022, indicated for staff to assist Patient 1 with Activities of Daily Livings (ADLs), transfers, mobility and to provide a safe environment for the patient at all times. 2. A review of Patient 2’s Admission Record indicated the facility admitted a seventy-four-year-old patient on 8/5/2022 with diagnoses that included repeated falls and dementia. A review of Patient 2’s MDS, dated 8/8/2022, indicated Patient 2 was severely impaired in cognitive skills. The MDS indicated the patient required extensive assistance with one person assist for bed mobility, transfers, toilet use and totally dependent with locomotion (how the patient moves between locations). A review of Patient 2’s Care Plan for Fall dated 8/6/2022, indicated for staff to assist Patient 2 with ADLs such as bed mobility and transfers. During an observation on 8/12/2022 at 10:30 am, with the Quality Assurance Nurse (QAN in the facility’s Red Cohort, there was a stand-up folding screen partition (divider) that served as a barrier between the Red Cohort and the Yellow Cohort (area for patients potentially exposed to COVID-19, mixed quarantine & symptomatic cohort). The QAN called CNA 1’s name through the barrier and there was no answer. There were spaces in between the divider enough to see there were three rooms in the Red Cohort. The QAN pointed at Room 8 and stated it was the charting room and bathroom for the Red Cohort and pointed at Room 9 with a closed door and stated there were two patients (Patients 1 and 2) in that room. During further observation of the closed door from Room 9, there was a clear, plastic trash bag wrapped around the door handle and tied to the handrail on the outside of the door. During an interview on 8/12/2022 at 10:34 am, CNA 2 came out of Room 7 in the Yellow Cohort, she peeked through the divider when asked to check what was on the door in Room 9. CNA 2 stated it looked like a trash bag was used to tie the door closed. During an observation and interview on 8/12/2022 at 10:35 am with the QAN, the QAN did not answer when asked what was on the door handle. The QAN immediately left and went out to the patio near the Red Cohort. CNA 1 was not at the patio area. The QAN went back to Room 9, inside the Red Cohort and the clear trash bag tied to the door handle was removed. During an observation on 8/12/2022 at 10:39 am, CNA 1 entered the door into the Red Cohort and went straight to the charting room. During an observation on 8/12/2022 at 10:43 am, Patient 1 was sitting on the toilet by herself. Patient 1 had a dark discoloration on her left eye. CNA 1 and QAN went inside Patient 1’s room and CNA 1 assisted Patient 1 back to bed. During a concurrent observation and interview on 8/12/2022 at 10:46 am, Patient 2 was lying in bed, talking incoherently to simple questions. Patient 2 was able to move both her arms and legs. During a concurrent observation and interview on 8/12/2022 at 10:50 am, there was a dark discoloration to Patient 1’s left eye, the QAN stated Patient 1 had a dark, maroon discoloration on her left eye and that the patient got the discoloration from a fall on 8/9/2022. Patient 1 did not answer when the surveyor asked for her name. During an interview on 8/12/2022 at 10:55 am, CNA 1 stated he left the facility and went to a store to buy food. CNA 1 stated he closed and tied Patient 1’s and 2’s door with a trash bag because Patient 1 kept walking out of the room. CNA 1 stated he was aware that it was wrong to leave the facility and it was wrong to use the trash bag to tie the patients’ door closed. During an interview on 8/12/2022 at 11:20 am, CNA 1 stated he did not communicate with other staff when he left his assigned area because they were busy. CNA 1 stated the only way he could ask other staff for help beyond the Red Zone was to yell out loud if there was a staff on the other side of the barrier. CNA 1 stated there was no work phone in the Red Cohort. During an interview on 8/12/2022 at 11:29 am, the Infection Preventionist Nurse (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated staff were not allowed to leave the facility and leave the patients unattended. During an interview on 8/12/2022 at 12:50 pm, CNA 3 stated Patient 1 liked to walk around, and Patient 2 had not attempted to get out of bed. CNA 3 stated Patient 2 was newly admitted to the facility, and she did not know if Patient 2 was able to ambulate (walk) or not. During an interview on 8/12/2022 at 1:06 pm, CNA 2 stated Patient 1 liked to walk and was at risk for falls because Patient 1 needed staff assistance for ambulation. During an interview on 8/12/2022 at 2:30 pm, CNA 2 stated “It is not okay to tie the door closed like that, that’s abuse.” During an interview on 8/12/2022 at 4:16 pm, CNA 3 stated staff should not tie the door closed from the outside because that was abuse and confinement. During an observation and interview on 8/12/2022, at 4:23 pm, a noise came from inside Patient 1’s room, CNA 3 stated it was Patient 1 who was trying to go outside. CNA 3 went inside the patient’s room. CNA 3 stated Patient 1 went back to bed. A review of the facility’s Policy and Procedure, titled “Abuse, Neglect and Misappropriation Prevention Program,” revised in April 2021, indicated “residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident’s symptoms.” The facility failed to ensure Patients 1 and 2 were free from involuntary seclusion. by failing to ensure: 1. CNA 1 did not leave Patients 1 and 2 inside their room involuntarily secluded without staff present in the Red Cohort. 2. CNA 1 closed Patient 1’s and 2’s door and tied the door handle with a clear trash bag to the handrail from the outside of the door to prevent the patients’ egress from the room while CNA 1 left his assigned area. These deficient practices violated Patients 1’s and 2’s rights and had the potential for Patients 1 and 2 to further experience incidents of involuntary seclusion that could lead to serious injury, and serious harm. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patients 1 and 2.