Other·October 27, 2023

§ 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. § 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 10/3/23, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate Facility Reported Incidents regarding patient abuse. As a result of the investigation, CDPH determined that the facility failed to ensure an abuse free environment for Patients 1, 2, and 3. This failure resulted in: a. Patient 1 experiencing physical abuse from Certified Nurse Assistant 1 (CNA 1). b. Patient 2 and 3 experiencing verbal abuse from Certified Nurse Assistant 2 (CNA 2) During a review of Patient 1’s Admission Record, the admission record indicated the patient was admitted to the facility on 11/23/22 with diagnoses that included schizophrenia (a disorder affecting a person’s ability to think, feel, and behave clearly) and tachycardia (a rapid heartbeat that may be regular or irregular). During a review of Patient 1’s Minimum Data Set (MDS, a patient assessment and care screening tool) dated 8/21/23, the MDS indicated Patient 1 had intact cognition (ability to understand and process information) and was independent with mobility (the ability to move). During an interview on 10/4/23 at 1:50 p.m., Kitchen staff (KS 1) stated KS 1 saw Patient 1 hit CNA 1 in the face and CNA 1 hit Patient 1 back on 9/16/23. KS 1 stated CNA 1 and Patient 1 were hitting each other. During an interview on 10/4/23 at 4:05 p.m., KS 2 stated KS 2 saw CNA 1 put CNA 1’s hands on Patient 1’s face and pushed Patient 1 against the wall. During an interview on 10/5/23 at 11:15 a.m., Assistant Program Director 1 (APD 1) stated Professional Assault Crisis Training (Pro-Act, a training program for organizations and agencies seeking to reduce or eliminate the use of restraint) was given to all staff who provided direct care to the patients. APD 1 stated, some Pro-Act principles applied when patients are being assaultive or aggressive to staff for safety of the patients themselves, others, and staff including: 1) Evade, 2) Wall restraint, 3) If a patient deescalates, we release restraint, continue communication, 4) Documentation, and 5) Always remind and reeducate to seek support from staff when frustrated. During a subsequent telephone interview on 10/6/23, at 1:54 p.m., KS 1 stated, Patient 1 and CNA 1 were hitting each other in the dining room. KS 1 stated KS 1 was picking up the tray cart with dirty dishes and stood about seven feet away from Patient 1 and CNA 1. KS 1 stated KS 1 heard CNA 1 say something to Patient 1 but couldn’t hear what CNA 1 said. KS 1 stated Patient 1 stared at CNA 1 and hit CNA 1's face with a closed fist. KS 1 stated CNA 1’s glasses flew off and CNA 1 hit Patient 1 back on Patient 1’s face. KS 1 stated the hit was harder than a push. KS 1 stated, CNA 1 grabbed Patient 1 by the shirt and pinned Patient 1 against the wall pushing Patient 1’s chest. KS 1 stated Patient 1 and CNA 1 both hit each other back and forth. KS 1 stated CNA 1 was very angry when Patient 1 hit CNA 1 on CNA 1’s face. KS 1 stated CNA 1 displayed a serious, wrinkled face, and CNA 1 was breathing heavily. KS 1 stated, three kitchen staff, the charge nurse, and other CNAs (unidentified) witnessed the incident (the altercation between CNA 1 and Patient 1). KS 1 stated, all staff were yelling, “no, no leave him,” telling CNA 1 to let go of Patient 1. During an interview, on 10/6/23, at 3:20 p.m., the facility Administrator (ADM) stated, staff needed to use the Pro-Act Protocol when a patient hit a staff member. The ADM stated the Pro-Act Protocol guided staff to verbally redirect the patients by telling the patients to stop, restrain the patients by placing staff’s hands on the patient’s body/chest area, and hold the patients against the wall, floor, or chair, but not touching the patients’ head. The ADM stated, if staff pushed the patients’ head, it would be considered pushing/hitting and physical abuse. b. During a review of Patient 2’s Admission Record, the admission record indicated Patient 2 was admitted to the facility on 11/23/22 with diagnoses that included unspecified schizophrenia and essential hypertension (high blood pressure without secondary causes). During a review of Patient 2’s MDS dated 7/10/23, the MDS indicated Patient 2 had intact cognition (ability to understand and process information) and was independent with mobility. During a review of Patient 3’s Admission Record, the admission record indicated Patient 3 was admitted to the facility on 6/1/23 with diagnoses that included unspecified schizophrenia and essential hypertension. During a review of Patient 3’s MDS dated 9/5/23, the MDS indicated Patient 3 had intact cognition and was independent with mobility. During an interview on 10/3/23, at 4:15 p.m., Patient 2 stated Patient 2 was going to a friend’s room to knock on the door on 9/29/23. Patient 2 stated Certified Nurse Assistant (CNA 2) told Patient 2 to quit acting stupid. During an interview, on 10/4/23, at 4:20 p.m., CNA 3 stated CNA 3 was on the other end of the hallway and heard CNA 2 told Patient 2 to go to Patient 2’s room with a loud voice. CNA 3 heard CNA 2 telling Patient 2, “Stop playing stupid,” with a loud voice. During a phone interview, on 10/5/23, at 1:03 p.m., Licensed Vocational Nurse 1 (LVN 1) stated LVN 1 and RN 1 were in East unit nurse’s station on 9/26/23 (untimed), when LVN 1 and RN 1 heard two people were haggling, shouting at each other. LVN 1 and RN 1 heard two voices but could not tell what they were saying. LVN 1 stated the shouting was coming from the Red Zone (area is only for patients who have laboratory-confirmed COVID-19 [Corona virus 2019, a contagious virus that causes mild to severe upper respiratory infection] in the East Unit. LVN 1 stated LVN 1 and RN 1 approached and told CNA 2, that CNA 2 was not supposed to be yelling [at the patients]. LVN 1 stated, LVN 1 and RN 1 went to CNA 2 and Patient 2 and told them both to stop. During an interview, on 10/5/23, at 3:30 p.m., RN 1 stated, RN 1 walked into the East Unit nurse’s station later in the evening of 9/29/23 (untimed) and while filing papers, RN 1 heard yelling coming from the corridor. RN 1 stated RN 1 came out and heard CNA 2 saying “you want to be acting stupid”, RN 1 kept hearing CNA 2 saying stupid. RN 1 stated, Patient 2 was standing at the door with his hands up. RN 1 stated, CNA 2 told RN 1 Patient 2 was not listening to CNA 2 and tried to go into the Red Zone staff restroom. RN 1 stated, Patient 3 had previously reported about a month ago to RN 1 that CNA 2 used derogatory word and called him a piece of “sh*t.” During an interview, on 10/5/23, at 3:50 p.m., Patient 3 stated, he had been living in the facility for four months. Patient 3 stated approximately a month and half to two months ago he was getting water and CNA 2 called him a piece of “sh*t” for no reason. Patient 3 stated, Patient 3 didn't want to cause trouble and forgot about it because Patient 3 wanted to go home. Patient 3 stated doesn’t want to see or talk to CNA 2. During a review of the facility’s Policy and Procedure (P&P) titled, "Abuse Prohibition," dated 2/23/21, the P&P indicated the facility prohibit abuse, mistreatment, neglect, misappropriation of patient property, and exploitation for all patients. The facility failed to ensure an abuse free environment for Patients 1, 2, and 3. This failure resulted in: a. Patient 1 experiencing physical abuse from CNA 1. b. Patient 2 and 3 experiencing verbal abuse from CNA 2. These violations jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patients 1,2 and 3.