Health inspection·October 27, 2022

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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 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. § 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. On 6/2/2022 at 1:10 pm, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding abuse to Patient 1. On 6/1/2022 at approximately 11 am, Patient 2 who had a history of inappropriate sexual behaviors toward female residents, went inside Patient 1’s room, sat on Patient 1’s bed, touched her chest, and tried to kiss Patient 1 while she was laying down on her bed. Patient 1 who was legally blind (lack or loss of ability to see) asked Patient 2 to stop and bit him on his chin. The facility failed to ensure Patient 1 was free from sexual abuse (non-consensual sexual contact of any type or sexual harassment) by failing to:protect Patient 1 from sexual abuse when Patient 2 touched Patient 1’s chest and tried to kiss Patient 1 on 6/1/2022. This deficient practice resulted in Patient 1 experiencing sexual abuse and feeling emotionally upset. a. A review of Patient 1’s Admission Record indicated the facility admitted a forty-three-year-old-female on 11/30/2021 with diagnoses that included legal blindness, hemiplegia (loss of strength) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke, a damage to the brain tissues due to a loss of oxygen to the area). A review of Patient 1’s History and Physical, dated 11/30/2021, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1’s Minimum Data Set (MDS, a patient assessment and care plan screening tool), dated 3/7/2022, indicated Patient 1 was moderately impaired in cognition (the patient ability to remember, understand, and make decisions) and required one-person extensive assistance (patient involved in activity, staff provided weight-bearing support) from staff with bed mobility, transfer, locomotion (movement) on and off the facility floor, dressing, eating, toilet use and personal hygiene. A review of Patient 1’s Situation Background Assessment and Review (SBAR, a tool used to aid in facilitating and strengthening communication between healthcare workers to minimize errors and miscommunication among healthcare professionals), dated 6/1/2022, indicated Patient 1 felt someone was in her bed, with his hands on her chest, and she told him (Patient 2) to stop and bit him on his chin. The SBAR indicated there was light blood stain on Patient 1’s face and her clothes and slight redness on Patient 1’s chin. A review of Patient 1’s Progress Notes dated 6/1/2022, timed 11:20 am, indicated Patient 1 screamed, and Licensed Vocational Nurse 2 (LVN 2) entered the patient’s room. The notes indicated Patient 1 had light blood stain on her face and clothes. The notes indicated Patient 1 did not know where she bit him (Patient 2) and believed she bit him on his chin. b. A review of Patient 2’s General Acute Care Hospital (GACH) record, titled “Psychiatric (a specialized medical doctor focusing on mental health) Initial Evaluation,” dated 5/11/2022 (14 days prior to Patient 2’s admission to the facility), indicated Patient 2 had a history of going inside female rooms and was found in one of the female patient’s rooms with his pants down showing his male genitalia (private area). A review of Patient 2’s GACH record, titled “History and Physical,” dated 5/11/2022, indicated Patient 2 entered a female patient’s room exposing himself and was placed on a 5150 (legal code allowing a person with a mental illness to be voluntarily detained for seventy-two (72) hours psychiatric hospitalization as this person can pose a danger to themselves and or others). A review of Patient 2’s Admission Record indicated the facility admitted a seventy-three-year-old-male on 5/25/2022 with diagnoses that included dementia (loss of memory and other mental abilities severe enough to interfere with daily life) with behavioral disturbance, and paranoid schizophrenia (a mental illness). A review of Patient 2’s Progress Notes dated 5/25/2022, timed at 6:51 pm, indicated the facility newly admitted the patient with diagnoses of 5150 and sexually inappropriate behavior. The notes indicated frequent visual checks were done for safety. A review of Patient 2’s untitled care plan, dated 5/25/2022, indicated the patient had a sexually inappropriate behavior, and the nursing and social worker interventions were to intervene as necessary to protect the rights and safety of others (patients and staff). A review of Patient 2’s SBAR notes dated 6/1/2022, indicated the patient had blood on his chin and shirt. The notes indicated Patient 2 reported to staff (unidentified) that another patient bit him. A review of Patient 2’s Social Service Progress Notes dated 6/1/2022, timed at 12:01 pm, indicated the Social Services Designee (SSD) met with Patient 2 on 6/1/2022. The notes indicated Patient 2 stated he was at his “girlfriend’s house and she just bit me out of nowhere.” The notes indicated the SSD reminded the patient not to enter other patients’ rooms without permission. A review of Patient 2’s Order Summary dated 6/1/2022, timed at 1:11 pm, indicated to transfer the patient to GACH for a psychiatric evaluation. During an observation and interview on 6/2/2022 at 1:48 pm, Patient 1 was awake sitting on a wheelchair inside her room. Patient 1 stated on 6/1/2022 before lunch, she felt someone was on her bed, touched her chest, and tried to kiss her. Patient 1 stated she asked the person to stop and bit him on the chin. During an interview on 6/2/2022 at 2:11 pm, Certified Nurse Assistant 1 (CNA 1) stated she saw blood on Patient 2’s shirt on 6/1/2022. During an interview on 6/2/2022 at 2:31 pm, LVN 1 stated Patient 1 was legally blind, alert, and oriented. LVN 1 stated Patient 2 had history of going inside other patients’ rooms. During a telephone interview on 8/31/2022 at 9:20 am, LVN 2 stated on 6/1/2022 at around 11 am, she heard a scream coming from Patient 1’s room and saw Patient 1 lying down on her bed with a blood stain on her face and on top of her shirt. LVN 2 stated Patient 1 reported that Patient 1 was not able to see a male person who sat on her bed, touched her chest, tried to kiss her, but she told him to stop, and bit him on the chin. LVN 2 stated Patient 1 was emotionally upset and repeatedly talking about the incident. During a telephone interview on 8/31/2022 at 9:47 am, and a review of Patient 2’s care plans, dated 5/25/2022, the Director of Nursing (DON) stated the care plan indicated Patient 2 had a sexually inappropriate behavior. The DON stated the interventions were for staff to monitor Patient 2’s closely. The DON stated the care plan indicated once a behavior was identified, an Interdisciplinary Team (IDT, a group of people with different functional expertise working toward a common goal) was necessary to discuss Patient 2’s history of inappropriate sexual behavioral. The DON stated the facility did not conduct an IDT to discuss Patient 2’s inappropriate sexual behavior. During a telephone interview on 9/1/2022 at 3:19 pm, the SSD stated Patient 2’s inappropriate sexual behavior was not addressed during the patient’s initial assessment. A review of the facility’s Policy and Procedure Abuse, titled “Neglect and Misappropriation Prevention Program,” with a revised date of April 2021, indicated the residents had the right to be free from abuse, neglect, misappropriation of patient property and exploitation but not limited to freedom from verbal, mental, sexual or physical abuse. The facility failed to ensure Patient 1 was free from sexual abuse by failing to protect Patient 1 from sexual abuse when Patient 2 touched Patient 1’s chest and tried to kiss Patient 1 on 6/1/2022. This deficient practice resulted in Patient 1 experiencing sexual abuse and feeling emotionally upset. The above violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.