Health inspection·April 12, 2024

F689 Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 2/28/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident abuse. As a result of the investigation, the facility failed to provide supervision during a smoking session for two residents (Residents 1 and 2), while Residents 1 and 2 were smoking at the facility's patio area. Resident 2 pushed a metal table and hit Resident 1's right lower leg and the facility's staff (Receptionist 2) did not notice/intervene. As a result, on 2/19/2024 at 9:15 pm, Resident 1 sustained a laceration on Resident 1's right lower leg measuring 14.3 centimeter (cm-unit of measurement) in length, by 1.9 cm in width and by 0.2 cm in depth. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 2/19/2024 at 9:25 pm and required 16 surgical staples (pieces of metal used to join up pieces of tissue to close large wounds or surgical cuts) for wound closure. Resident 1 suffered a 7 out of 10 pain (on a 0 to 10 pain score, 0 = no pain at all and 10 = worst imaginable pain) due to Resident 1's right lower leg laceration. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1, a 63-year-old male on 5/4/2023 and readmitted the resident on 12/1/2023, with diagnoses that included hypertension (increased blood pressure), tobacco use (smoking, cigarettes inhalation), and depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/18/2023, indicated Resident 1 had clear speech and intact cognitive function. Resident 1 required supervision or touching assistance for dressing and chair/bed-to-chair transfers. The MDS indicated Resident 1 used a wheelchair for mobility and able to wheel 150 feet with two turns once seated in the wheelchair. A review of Resident 1's History and Physical (H&P) dated 12/30/2023, indicated Resident 1 had the capacity to make medical decisions. A review of Resident 2's AR indicated the facility admitted Resident 2, a 56-year-old male on 2/5/2024, with diagnoses that included nicotine dependence and bipolar disorder. A review of Resident 2's MDS dated 2/11/2024, indicated Resident 2 had clear speech and intact cognitive function. The MDS indicated Resident 2 required supervision or touching assistance for eating, personal hygiene, sit to stand, and walking for 50 feet. A review of the facility's Room Change Form (RCF), dated 2/15/2024, indicated Resident 2 was moved to a different room on 2/15/2024 due to Resident 2 was not compatible with Resident 1. The RCF indicated Residents 1 and 2 yelled at each other because they disliked each other's attitude. The RCF indicated the reason for room change was for Resident 1 and 2's health/safety issues. A review of Resident 2’s undated and untitled care plan (CP) indicated Resident 2 had a room change and had a behavior problem due to Residents 1 and 2 yelling at each other and disliked each other's attitude. The CP indicated the approach intervention was for staff to intervene during a resident-to-resident altercation to protect the rights and safety of Residents 1 and 2 and remove the residents from the situation. A review of Resident 1's Progress Notes (PN), dated 2/19/2024, timed 11:34 pm, indicated Resident 1 had an altercation with Resident 2 in the patio on 2/19/2024 at "around" 9:15 pm. The PN indicated Resident 1 was sitting in the wheelchair with 11 cm laceration on the right lower leg. The PN indicated 911 was called and Resident 1 was sent to GACH 1 on 2/19/2024 at approximately 9:25 pm. A review of Resident 1's Change in Condition (COC) Evaluation dated 2/19/2024, timed 11:52 pm, the COC indicated on 2/19/2024, Resident 1 had a laceration with bleeding on the right lower leg requiring sutures. The COC indicated Resident 1 experienced an acute pain on the right lower leg at a level of 7 out of 10. A review of GACH 1's After Visit Summary (AVS) dated 2/19/2024, indicated Resident 1 had a right lower leg laceration and received laceration repair. The AVS indicated Resident 1's laceration was closed with surgical staples. A review of Resident 1's PN dated 2/20/2024, timed 1:05 am, indicated Resident 1 arrived at the facility on a gurney. The NP indicated Resident 1 was readmitted to the facility from GACH 1 with a diagnosis of laceration to the right lower leg. The PN indicated Resident 1 had 16 staples on the right lower leg. A review of Resident 1's Skin Observation Checks (SOC), dated 2/20/2024, timed 8:17 am, indicated Resident 1 had 16 staples at the right lower leg due to laceration. The SOC indicated the size of laceration was measured at 14.3 cm in length by 1.9 cm in width by 0.2 cm in depth. During an observation and concurrent interview with Resident 1 on 2/28/2024 at 11:28 am, in Resident 1's room, Resident 1 was lying in bed with the right leg elevated by a folded blanket. Resident 1's right lower leg was wrapped with rolling gauze. Resident 1 stated, Resident 2 was Resident 1's roommate. Resident 1 stated Resident 2 "always" asked Resident 1 for cigarettes and yelled at Resident 1. Resident 1 stated Resident 1 reported the incidents to the Administrator (ADM) and the ADM did a room change for Resident 2 on 2/15/2024. Resident 1 stated, (on 2/19/2024), during scheduled smoking time "around" 9 pm at the smoking area in the patio, Resident 2 kept asking Resident 1 for cigarette. Resident 1 stated when Resident 1 refused to give Resident 2 cigarette, Resident 2 became angry and threw the patio table toward Resident 1. Resident 1 stated the table hit Resident 1's right leg causing it to bleed. Resident 1 stated, the right leg was so painful, and Resident 1 was very angry. Resident 1 stated there was no staff outside at the patio at the time to stop Resident 2 when Resident 2 threw the table towards Resident 1's leg. During an interview with Registered Nurse 1 (RN 1) on 2/29/2024 at 9:45 am, RN 1 stated, on 2/19/2024, at "around" 9 pm, RN 1 received a report from Certified Nursing Assistant 3 (CNA 3) that Residents 1 and 2 got into an altercation outside in the patio area. RN 1 stated, RN 1 immediately went to the patio and saw Resident 1 sitting in his wheelchair with blood dripping from Resident 1's right lower leg. RN 1 stated there was blood on the ground, and a table (metal) was on the ground next to Resident 1, and Resident 2 was standing next to the activity door. RN 1 stated RN 1 did not see other residents or facility staff outside at the patio area. RN 1 stated, there was a long skin cut/laceration, about 11 cm in length, that was bleeding from Resident 1's right lower leg. RN 1 stated, Resident 1 was sent to GACH 1 on 2/19/2024 at "around" 9:30 pm and came back on 2/20/2024, at 1:05 am with 16 staples on Resident 1's right lower leg. During an interview with Receptionist 2 (RT 2) on 2/29/2024 at 10:28 am, RT 2 stated, the facility's scheduled smoking time were at 9 am, 1 pm, 5 pm and 9 pm. RT 2 stated RT 2 was assigned and responsible for supervising all smokers during smoking sessions. RT 2 stated, on 2/19/2024 during the 9 pm smoking session, RT 2 wheeled another smoker (Resident 9) in the wheelchair back inside Resident 9's room and left Residents 1 and 2 unattended outside in the patio. RT 2 stated the incident between Residents 1 and 2 happened right after RT 2 left the patio. During an interview with Resident 8 on 2/29/2024 at 10:52 am, Resident 8 stated, that night (on 2/19/2024) at "around" 9 pm, Resident 8 saw (through Resident 8's sliding glass door) Resident 1 smoking a cigarette, and Resident 2 was trying to take the cigarette from Resident 1. Resident 8 stated, beside Residents 1 and 2 were outside in the patio, Resident 8 did not see any staff member in the patio supervising Residents 1 and 2 while Residents 1 and 2 were smoking. During an interview with CNA 3 on 2/29/2024 at 11:36 am, CNA 3 stated, on 2/19/2024 during the night shift (unable to recall the time), CNA 3 was in Resident 8's room providing care. CNA 3 stated, CNA 3 saw, (through Resident 8's sliding glass door) Resident 1 was holding a cigarette smoking, and Resident 2 was walking around Resident 1. CNA 3 stated, CNA 3 saw Resident 2 pushed a patio table towards Resident 1, hit Resident 1 and the table landed next to Resident 1. CNA 3 stated, there was no staff supervising Residents 1 and 2 at the time when the incident happened. CNA 3 stated RT 2 was responsible for supervising the residents during smoking session, but CNA 3 did not see RT 2 at the patio area. During an interview with the ADM on 2/29/2024 at 12:04 pm, the ADM stated, Residents 1 and 2 used to be roommates. The ADM stated, the ADM received a complaint from Resident 1 that Resident 1 had been bothered by Resident 2 for cigarettes. The ADM stated, the facility did a room change on 2/15/2024 to keep Resident 1 and Resident 2 away from each other. The ADM stated, smoking sessions needed to be supervised by staff to ensure residents' safety. During an interview with the Director of Nursing (DON) on 3/1/2024 at 11 am, the DON stated, the facility needed to provide supervision to keep all residents safe and to prevent injury. The DON stated Residents 1 and 2 did not like each other, and that was the reason the facility's ADM did the room change for Resident 2. The DON stated, Residents 1 and 2 should not have been left together alone without supervision during smoking time to prevent the possible conflict between them. The DON stated, Resident 1's injury could be prevented when proper supervision was provided to Residents 1 and 2. During a review of the facility's Policy and Procedure (P&P) titled, "Smoking," dated 10/2/2023, the P&P indicated "Resident will be supervised by facility staff while smoking. All smoking sessions will be supervised by facility staff members." The facility failed to provide supervision during a smoking session for Residents 1 and 2, while Residents 1 and 2 were smoking at the facility's patio area. Resident 2 pushed a metal table and hit Resident 1's right lower leg and the facility's staff did not notice/intervene. As a result, on 2/19/2024 at 9:15 pm, Resident 1 sustained a laceration on Resident 1's right lower leg measuring 14.3 cm in length, by 1.9 cm in width and by 0.2 cm in depth. Resident 1 was transferred to General Acute Care Hospital 1 on 2/19/2024 at 9:25 pm and required 16 surgical staples for wound closure. Resident 1 suffered a 7 out of 10 pain due to Resident 1's right lower leg laceration. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.