Health inspection·March 22, 2024

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. § 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. § 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 9/8/2024 at 9:45 am., the California Department of Public Health (DCPH, the Department) conducted an unannounced abbreviated standard survey visit. As a result of the investigation, the Department determined the facility failed to protect the resident's right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for Resident 2 on 2/7/2024, at 2:50 p.m., when Resident 1 punched Resident 2 three times on the face. Resident 2 was subjected to physical abuse from Resident 1 and sustained a laceration (a pattern of injury in which skin and underlying tissues are cut or torn) on the left eyebrow. A review of Resident 1's admission record, the admission record indicated Resident 1 was a 52-year-old male and Resident 1 was admitted to the facility on 10/18/2023 with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). A review of Resident 1's "Minimum Data Set (MDS, a standardized assessment and care screening tool)," dated 1/22/2024, the "MDS" indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The "MDS" indicated Resident 1 was independent (resident completes activity by themselves) on staff for dressing, eating, and personal hygiene. A review of Resident 2's admission record, the admission record indicated Resident 2 was a 49- year-old male and Resident 2 was admitted to the facility on 11/9/2023 with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and hypertension (high blood pressure). A review of Resident 2's "MDS," dated 11/15/2023, the "MDS" indicated Resident 1 had no impairment in cognitive skills (ability to make daily decisions). The "MDS" indicated Resident 1 was independent (resident completes activity by themselves) on staff for dressing, eating, and personal hygiene. During an interview on 2/8/2024 at 10:50 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 2/7/2024, around 3 p.m., while CNA 1 was monitoring residents in the yard CNA 1 saw Resident 1 on top of Resident 2. CNA 1 stated Resident 2 had a cut on the eyebrow area. During a concurrent observation and interview on 2/8/2024 at 11:39 a.m., with Resident 2, Resident 2 had a bandage over his left eyebrow. Resident 2's left eyelid was red. Resident 2 stated Resident 2 walked up to a resident (unidentified) to talk to him, and the (unidentified) resident hit Resident 2 and caused a cut to Resident 2's eyebrow. Resident 2 stated the incident took place in the courtyard. Resident 2 stated Resident 2 was taken to the hospital where Resident 2 received four stitches (sutures, sterile surgical threads used to repair wounds) to his eyebrow. During an interview on 2/8/2024 at 11:48 a.m. with Resident 1, Resident 1 stated Resident 1 was sitting on a bench when Resident 2 walked up to Resident 1 and had his hands out like Resident 2 was going to put Resident 2's hands around Resident 1's neck. Resident 1 stated Resident 1 brushed Resident 2's hand away. Resident 1 stated Resident 2 tried to swing at Resident 1. Resident 1 stated Resident 1 punched Resident 2 three times. During an interview on 2/8/2024 at 12:47 p.m. with Primary Counselor (PC) 1, PC 1 stated on 2/7/2024, PC 1 was monitoring residents during smoke break. PC 1 stated Resident 1 was sitting on a bench in the yard and Resident 2 walked up to Resident 1 and swung at Resident 1 and then Resident 1 hit Resident 2 three times. PC 1 stated Resident 2 had blood on the face. A review of Resident 1's "Progress Notes," dated 2/8/2024, the "Progress Notes" indicated on 2/7/2024, "Peer (Resident 2) attempted to put his hands around resident's (Resident 1) neck area and in response resident (Resident 1) hit peer (Resident 2) in left face/eyebrow." A review of Resident 2's "Progress Notes," dated 2/8/2024, the "Progress Notes" indicated on 2/7/2024, "Resident (Resident 2) attempted to put his hands around peers' (Resident 1's) neck, peer (Resident 1) reacted by hitting resident (Resident 2) with injury of a 4.0 x 0.3 cm X 0.1 cm laceration to eyebrow." A review of Resident 2's untitled General Acute Care Hospital (GACH) records, the GACH records indicated Resident 2 was seen at the emergency department for a laceration of the left eyebrow. The GACH records indicated Resident 2 should return to the emergency department in five to seven days to have the stitches taken out. A review of the facility's Policy and Procedure (P&P) titled, "Abuse Prohibition," reviewed 2/23/2021, the P&P indicated, "Health Care Centers prohibit abuse... This includes, but is not limited to, freedom from corporal punishment, Involuntary seclusion, and any physical or chemical restraint ..." The P&P indicated, "Physical Abuse includes hitting, slapping, pinching, kicking, etc." The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 1 and Resident 2.