Health inspection·August 29, 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. 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 7/12/2024 at 12 p.m., the California Department of Public Health (CDPH, the Department) conducted an unannounced abbreviated standard survey visit to investigate a facility reported incidents regarding resident-to-resident altercations. As a result of the investigation, the Department determined the facility failed to ensure Resident 1 and Resident 3 were free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) from Resident 2 in accordance with Resident 2’s care plan (CP) and the facility’s policies and procedures (P&P). As a result, Resident 2 hit Resident 1 on the mouth and hit Resident 3 on the face. Resident 1 had bruising, and pain on the mouth, and Resident 1 did not feel safe in the facility. A review of Resident 1’s “Admission Record (AR),” the “AR” indicated, Resident 1 is a 39-year-old male and was admitted to the facility on 1/30/2020 with multiple diagnoses including schizophrenia and nicotine dependence. During a review of Resident 1’s physician’s “Progress Note (PN),” dated 6/11/2024, the “PN” indicated, Resident 1 was alert and oriented to self and situation. During a review of Resident 1’s “eINTERACT Change in Condition Evaluation (COC, a sudden clinically important deviation from a patient’s baseline in physical, cognitive, behavioral, or functional domains),” dated 6/27/2024, timed at 5:19 p.m., the “COC” indicated, at approximately 5:15 p.m. on 6/27/2024 in hallway (Area 1), Resident 1 was hit by peer [Resident 2] once in the mouth area with right-hand closed fist. During a review of Resident 1’s “PN,” dated 6/27/2024, timed at 5:20 p.m., the “PN” indicated, due to an episode of aggression from peer, Resident 1 was educated on the importance of maintaining socially appropriate boundaries with others. During a review of Resident 1’s “Interdisciplinary Notes (IDT),” dated 6/28/2024, timed at 8:31 a.m., the “IDT” indicated, Resident 1 got hit by peer in the mouth on 6/27/2024. A review of Resident 1’s “Minimum Data Set (MDS, an assessment and screening tool),” dated 7/1/2024 indicated, Resident 1’s cognition was intact. The MDS indicated, Resident 1 had behavior of hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality) and Resident 1 was independent with activities of daily living (ADL). A review of Resident 3’s “AR,” indicated, Resident 3 is a 35-year-old male and was admitted to the facility on 10/20/2017 with multiple diagnoses including schizoaffective disorder (a mental condition that causes both a loss of contact with reality (psychosis) and mood problems [depression or mania]), hyperlipidemia (high cholesterol, a condition in which there are high levels of fat particles (lipids) in the blood) and nicotine dependence, unspecified, uncomplicated. A review of Resident 3’s physician’s “PN,” dated 5/28/2024 indicated, Resident 3 was alert and oriented to self and situation. A review of Resident 3’s “MDS,” dated 6/10/2024, the indicated Resident 3’s cognition status was intact. The MDS indicated, Resident 3 had a behavior of delusions and was independent with ADL. A review of Resident 3’s “COC,” dated 7/3/2024, timed at 6:25 p.m. indicated Resident 3 was hit by peer (Resident 2). A review of Resident 3’s “PN,” dated 7/3/24, timed at 6:25 p.m. indicated, at approximately 6:20 p.m. on 7/3/24 in the Area 1 hallway, peer hit Resident 3 in the face area once with peer’s right closed fist. A review of Resident 3’s “PN,” dated 7/3/2024, timed at 7:27 p.m. indicated due to an episode of aggression from peer, Resident 3 was educated on the importance of maintaining socially appropriate boundaries with others. A review of Resident 3’s “IDT,” dated 7/5/2024, timed at 9:11 a.m., indicated Resident 3 got hit by peer in the face area on 7/3/2024. A review of Resident 2’s “AR,” indicated Resident 2 is a 42-year-old male and was admitted to the facility on 9/27/2023 with diagnoses of schizophrenia unspecified and essential hypertension. A review of Resident 2’s untitled CP initiated 5/19/2024 indicated the interventions included to remove Resident 2 from environment, if needed. During a review of Resident 2’s untilled CP initiated 6/27/2024 indicated Resident 2 will not be hearing voices and not hit peers for thirty (30) days. The “CP” indicated, one of the interventions was to encourage Resident 2 to walk in the hallway, when there were no peers around. During a review of Resident 2’s physician’s “PN,” dated 6/18/2024 indicated, Resident 2 was alert and oriented to self and situation. During a review of Resident 2’s “COC,” dated 6/27/2024, timed at 5:15 p.m., indicated at approximately 5:15 p.m. on 6/27/2024 in Area 1 hallway, Resident 2 hit peer once on the mouth area with his right hand. During a review of Resident 2’s “PN,” dated 6/27/2024, timed at 5:20 p.m., indicated due to an episode of physical aggression towards peer, Resident 2 was educated on the inappropriateness of physical aggression and the importance of maintaining appropriate social boundaries towards peers. A review of Resident 2’s “IDT,” dated 6/28/2024, timed at 8:18 a.m., indicated Resident 2 hit peer in the mouth in the hallway on 6/27/2024 at 5:15 p.m. A review of Resident 2’s “MDS,” dated 7/1/2024, indicated Resident 2’s cognition status was intact. The MDS indicated, Resident 2 had a behavior of delusions and Resident 2 was independent with ADL. During a review of Resident 2’s “PN,” dated 7/3/2024, timed at 6:25 p.m., indicated at approximately 6:20 p.m. on 7/3/2024 in Area 1 hallway, Resident 2 hit peer in the face area once with his right closed fist. During a review of Resident 2’s “IDT,” dated 7/5/2024, timed at 9:05 a.m., indicated Resident 2 hit peer in the face area once on 7/3/2024 at 6:20 p.m. During a concurrent observation and interview on 7/12/24 at 1:44 p.m. with Resident 1, Resident 1 had a flat affect (severely restricted or nonexistent expression of emotion) and an old bruise (faded blue) on the left lower lip. Resident 1 stated, Resident 2 hit Resident 1 “real hard” in the mouth while standing in Area 1 (unable to recall date). Resident 1 stated, Resident 1 had pain. Resident 1 stated, this was the second time Resident 2 hit Resident 1. Resident 1 stated, Resident 1 did not feel safe in the unit and Resident 1 had seen Resident 2 walked past Resident 1 (after the incident) “all the time.” During a concurrent observation and interview on 7/12/2024 at 3:03 p.m. with Resident 3, Resident 3 appeared slightly anxious but maintained eye contact. Resident 3 stated, Resident 3 was standing in front of his room located in Area 1 hallway while lining up for lunch or dinner “I don’t remember,” when Resident 2 hit Resident 3 in the face. Resident 3 stated, Resident 2 hit Resident 3 in the nose and Resident 2 had hit “people in other units too.” During a concurrent observation and interview on 7/12/24 at 4:17 p.m. with Resident 2, Resident 2 had a flat affect and occasionally paused and stared. Resident 2 stated, Resident 2 had hit “a couple of people,” including Resident 1 and Resident 3 and “spit on a nurse.” Resident 2 stated, he hit Resident 1 and Resident 3 because Resident 2 was mad. During an interview on 7/16/2024 at 11:42 a.m., Resident 7 stated, Resident 2 had been moved from other units and Resident 2 was trouble in the past when Resident 2 fought with other residents including Resident 1. During an interview on 7/16/2024 at 2:23 p.m., the Behavioral Specialist (BS) stated, Resident 1 was waiting in line for grooming when Resident 2 was walking by and the BS saw Resident 2 swung Resident 2’s right hand at Resident 1’s mouth area. The BS stated, the BS could not remember the date when incident happened, but the incident happened in the afternoon. The BS stated, Resident 2 and Resident 3 were walking towards the lunch line and the BS saw Resident 2 hit Resident 3 in the face. The BS stated, the BS could not remember the date of when the incident happened. The BS stated, the BS “could have done a lot of things,” about safety for the residents “but I could not predict the future.” The BS stated, it was important the facility ensured close monitoring for Resident 2 and “was separated to avoid any close encounters with the residents” to prevent any further incident and for resident safety. During an interview on 7/16/2024 at 3:23 p.m., the Licensed Vocational Nurse (LVN) stated, Resident 2 has had some incidents [resident to resident altercations] with residents and Resident 2 has been moved to different units [due to the altercations]. The LVN stated, it was important to separate residents “cuz we don’t want them to hit each other, get verbally aggressive, or trigger anybody else, in particular with” Resident 2. During an interview on 7/16/24 at 4:15 p.m., with the Director of Nursing (DON), the DON stated, one of the interventions for Resident 2 was for staff to encourage Resident 2 not to walk in the same area where other residents were walking, this was for resident safety. A review of the facility’s P&P titled, “Abuse Prohibition,” effective date 2/23/202, indicated Healthcare Centers (facility) prohibit abuse, mistreatment, neglect, misappropriation of resident’s property, and exploitation for all residents. The P&P indicated the Center will implement an abuse prohibition program through one of the following: prevention of occurrences. The P&P indicated, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. The P&P indicated, physical abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. The P&P indicated, the Center ensures that staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property for all patients. A review of the facility’s policy titled “Resident Rights,” revised 12/2021, indicated “Federal and state laws guarantee certain basic rights to all residents of this facility.” The P&P indicated, one of these rights included the resident’s right to be free from abuse, neglect, misappropriation of property, and exploitation. A review of the facility’s “Reported Incidents 2024 (RI),” list, dated from 1/2024 to 7/3/2024, indicated Resident 2 has had four (4) incidents of physical aggression this year on the following dates: 1/19/2024, 5/19/2024, 6/27/2024 and 7/3/2024. As a result of the investigation, the Department determined the facility failed to ensure Resident 1 and Resident 3 were free from physical abuse from Resident 2 in accordance with Resident 2’s CP and the facility’s P&P. As a result, Resident 2 hit Resident 1 on the mouth and hit Resident 3 on the face. Resident 1 had bruising, pain on the mouth, and did not feel safe in the facility. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 3.