Other·February 2, 2024

F600 Patient Abuse The patient has the right to be free from abuse, neglect, misappropriation of patient 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 patient ’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.

F740 §483.40 Behavioral health services. Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. On 12/15/23 at 11:08 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding patient-to-patient physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury). As a result of this investigation, the department determined that the facility failed to: Implement the facility’s policy and procedure titled “Procedure for Prevention of Patient abuse and mistreatment," by failing to accurately assess and provide the necessary behavioral health care and services to Patient 2 with diagnosis of schizoaffective disorder (a chronic and severe mental disorder that affects how a person thinks, feels, behaves and experience psychosis [behavioral symptoms that affect the mind, and loss of contact with reality]) and recent history of "increase agitation, aggressive behavior toward staff," and "paranoid delusion (profound fear and loss of the ability to tell what's real and what's not real) believing other people are against him causing outburst of anger." 1. Ensure the Licensed Vocational Nurse (LVN) appropriately assess and monitor Patient 2's aggressive behaviors. 2. Administer Ativan (medication used to relieved anxiety [fear of the unknown]) and Haldol (a medication used to control mood and behavior) as ordered by the physician for Patient 2 on 10/30/23 with history of angry outburst. 3. Ensure the Certified Nursing Assistants (CNA) consistently monitor Patient 2 for safety whereabouts every two hours as indicated in the facility's policy and procedure. 4. Develop a care plan to address and provide interventions on how to manage the paranoid and delusional behavior of the Patient 2. 5. Review Patient 2's clinical records prior to the admission to the facility and when admitted to the facility on 10/30/23 was not reviewed by the facility to ensure Patient 2 was properly placed in the facility. As a result of this deficient practice, Patient 2 entered Patient 1’s room (located adjacent to patient 2’s room) without supervision, had a delusional thought (belief that is clearly false and that indicates an abnormality in the affected person's content of thought) that Patient 1 was raping (to force someone to have sex when the person is unwilling, using violence or threatening behavior) him and pounded on Patient 1’s head that resulted in a laceration (deep skin cut) of the left forehead and was hospitalized for suture (stitches holding together the edges of a wound) placement above the left eyebrow and experienced chest pain, headache and felt traumatized from being abused by Patient 2. Patient 2 had delusional which occurred 13 hours after Patient 2 was admitted to the facility. A review of Patient 1's Admission Record indicated Patient 1 was originally admitted to the facility on 7/5/23 and readmitted on 11/3/23. Patient 1's diagnoses that included polyneuropathy (a nerve damage that causes pain, decreased ability to move and feel because of nerve damage) and dementia (a brain disorder that causes gradual decline in memory and thought process). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 11/7/23, indicated Patient 1 had the ability to understand others and express own ideas and wants, that required partial assistance (helper does less than half the effort) to walk ten feet distance, transfer to and from a bed to a chair, and changing position from sitting to standing. A review of Patient 1's "COC (Change of Condition)/INTERACT ASSESSMENT FORM SBAR (Situation Background Assessment and Recommendation -a communication tool that allows health professionals to communicate clearly about the Patient's condition)" dated 10/31/23, timed at 6:53 AM, indicated, on 10/31/23 at 3:30 AM, a CNA was calling for help in Patient 1's room when the CNA found Patient 2 pounding (repeated and heavy striking or hitting someone or something) on Patient 1. A head-to-toe assessment was conducted and noted Patient 1 with left eyebrow abrasion measuring 3 cm (centimeter- a unit of measurement) x 0.5 cm with slight bleeding and right eyebrow abrasion measuring 0.5 cm x 0.5 cm and left forehead swelling. A review of the GACH (General Acute Care Hospital) record, dated 10/31/23, timed at 12:33 PM, indicated Patient 1 was admitted to the ER (Emergency Room) due to headache, chest pain and laceration (deep cut) of the forehead measuring three centimeter in length, that required three sutures and given Morphine Sulfate (MS- a medication given for severe pain). The GACH record indicated Patient 1 reported being assaulted by another patient at the nursing facility and was punched on the left side of the head in the middle of the night. During an interview on 12/4/23, at 3 PM with Patient 1's Family (FAM), FAM stated, she was informed by Patient 1 that on 10/31/23 at 3:30 AM, he was beaten up by another patient (Patient 2) and was bleeding on his head with left side eye brow wound and resulted in four-days hospital stay. FAM also added, Patient 1 told her he was traumatized, could not stop shaking and had muscle spasm after the incident happened. A review of Patient 2's History and from General Acute Care Hospital (GACH), dated 10/10/23, indicated Patient 2 was admitted in the psychiatric (a unit in the hospital that focus patients with mental and behavioral care) unit of the hospital due to aggressive behavior. A review of Patient 2's Admission Record indicated Patient 2 was originally admitted to the facility on 10/30/23 with diagnoses that included traumatic brain injury (brain injury usually results from a violent blow or jolt to the head or body that affects the persons mood and behavior such as aggression, combativeness, or other unusual behavior) and schizoaffective disorder. A review of Patient 2's "Nursing Home Visit", dated 10/30/23, indicated Patient 2's initial History & Physical (H&P, a document that contains the physician's examination of a Patient) upon admission to the facility with diagnoses that included recent hospitalization due to aggressive behavior. A review of Patient 2's Order Summary report, dated 10/30/23, indicated the physician ordered to administer Haloperidol to Patient 2 for behavior problem related to "paranoid delusion believing other people are against him causing outburst of anger," Haloperidol 5 mg (milligram, a unit of weight measurement) to be given by mouth three times a day for schizoaffective disorder. A review of Patient 2's Medication Administration Record, indicated the Haloperidol was ordered on 10/30/23 at 4PM. The MAR indicated Patient 2 was not administered Haldol on 10/30/23. The MAR indicated Haldol was first administered to Patient 2 on 10/31/23 at 8 AM, (five hours after Patient 2 pounded on Patient 1’s the head on 10/31/23 at 3:30 AM). A review of Patient 2's "COC (Change of Condition/INTERACT ASSESSMENT FORM SBAR, dated 10/31/23, at 3:35 AM, indicated "A staff saw Patient 2 pounding at Patient 1 because Patient 2 thought that Patient 1 was raping him for some reasons." A review of Patient 2's MDS, dated 11/1/23, indicated Patient 2 had the ability to understand others and express own ideas and wants. The MDS indicated Patient 2 was able to walk 150 feet distance without the need of an assistive device, and without impaired range of motion (limit to which a part of the body can be moved) on both upper and lower extremities. A review of Patient 2's Order Summary Report, on 10/30/23 the physician ordered to administer Ativan to Patient 2 for "increase agitation, aggressive behavior toward staff," The record also indicated; Ativan 1 mg was ordered to be given by month every 6 hours as needed. A review of Patient 2's MAR, indicated, Ativan was ordered on 10/30/23 at 4PM, The MAR indicated Patient 2 was not administered Ativan as needed on 10/30/23. A review of Patient 2's Order Summary Report, dated 10/30/23, indicated Patient 2 the physician's ordered the staff to monitor behavior every shift related to agitation, aggressive toward staffs, and delusion and document hashmarks of "0" (meaning. no agitation, no delusion episode) or "1" (meaning, agitation or delusion presented) with the start date of 10/30/23. A review of Patient 2's Medication Administration Record, indicated, on 10/30/23 from 11 PM to 7 AM, during the night shift, Licensed Vocational Nurse (LVN) documented "0" (no agitation or aggressive behavior and no delusion presented), following the abusive event on 10/31/23 at 3:35 AM. During an observation conducted on 12/15/23 at 12:56 PM, Patient 1 and Patient 2's rooms had a shared/common restroom located between each of their rooms. During an interview on 12/15/23 at 1:30 PM with Registered Nurse Supervisor (RNS), RNS stated that she did not assess and did review Patient 2’s clinical records during admission to the facility that indicated Patient 2 had diagnosis of schizophrenia disorder related to aggressive behaviors. The RNS stated, she did not read Patient 2's H&P because she was not the admitting nurse for the patient. The RNS stated, the admitting nurse should have reviewed Patient 2's H&P, diagnoses, and physicians’ orders to make sure the right care could be provided to Patient 2. The RNS stated for Patient 2 with history of aggressive behaviors, the patient must be monitored closely upon admission to prevent potential accidents and abuse. During a concurrent interview and record review on 12/15/23 at 2:20 PM with LVN 2, Patient 2's medical record was reviewed. LVN 2 stated, per H&P, Patient 2 was admitted to the hospital prior to transferring to the facility with chief complaint of aggressive behavior. LVN 2 stated his history of aggressive behaviors should have been addressed in the baseline care plan with strict monitoring for the safety of staffs and other Patients per protocol. LVN 2 added, without the baseline care plan for aggressive behavior, the staffs were not aware, and Patient 2 was not properly monitored to prevent Patient-to-Patient abuse or altercation. LVN 2 stated, she must have overlooked and did not review Patient 2’s H&P and the admission package, which was very important to review, because the physical abuse and incident could have been prevented. During an interview on 12/15/23 at 4:05 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated the facility's policy and procedure indicated to keep the Patients safe, the CNA's will visually monitor the Patients for safety every 2 hours. CNA 1 stated all CNAs were responsible to document their assigned Patients' whereabout every 2 hours for safety. During an interview with Director of Staff Development (DSD) on 12/15/23 at 4:45 PM, the DSD stated, LVNs and the RNS should had been checking and reminding the CNAs to document on time for their tasks and Patients' whereabout because conducting timely monitoring and documentation is important to keep track of patients and prevent accidents. During an interview on 12/15/23 at 5 PM with LVN 1, LVN 1 stated she was familiar with the altercation between Patient 1 and Patient 2. LVN 1 stated that she was not aware that Patient 2 had an aggressive behavior because she did not read Patient 2's H&P. LVN 1 stated, she should have reviewed all new Patients' admission information before taking care of the Patient 2. During an interview on 12/15/23 at 5:42 PM with the Director of Nurses (DON), the DON stated, according to the facility's policy, patients in the facility are monitored every 2 hours by the CNAs. The DON stated that monitoring the patients with aggressive behavior was important in preventing acts of abuse. The DON stated that monitoring was even more important on new Patients with history of aggressive behavior. During an interview on 12/15/23 at 6 PM with the Director of Nurses (DON), the DON stated, nursing staff including the admitting nurses, RNS, LVNs and charge nurses were expected to review new Patient's admitting package before taking care of them. DON stated, RNS and LVN charge nurse should know how to do the care plan. During an interview and concurrent record review on 12/15/23 at 6 PM with the DON, Patient 2's "Documentation Survey Report" for monitoring Patient location every 2 hours was reviewed. The record indicated, there were missing entries in the CNA's monitoring log that indicated Patient 1 and Patient 2 were not monitored every two hours consistently on 10/30/23 at 4 PM, 6 PM, 8 PM, 10 PM, and on 10/31/23 at 12 AM, 2 AM, 4 AM. The DON stated that if there was no documentation, then the facility staffs did not provide supervision to Patient 2 at those times. The DON stated that with enough supervision and proper monitoring, Patient 1's incident of being pounded on the head by Patient 2 on 10/31/23, at 3:35 AM could have been prevented. During an interview on 12/15/23 at 6:30 PM with the Administrator (ADM), the ADM stated, if the documentation was blank, it meant the facility staffs did not do their job. During an interview on 12/20/23 at 12:15 PM, during a telephone interview, Patient 1 stated he was sitting in bed watching television on 10/30/23 at around 3AM when Patient 2, who he had not met before, entered his room, and hit him on the head multiple times. Patient 1 stated, he called for help multiple times before a staff arrived to stop Patient 2 from hitting him. Patient 1 stated, he was bleeding on the head and was afraid of Patient 2. Patient 1 added, he was transferred to the hospital the next day around noon when he experienced severe headache and chest pain and a cut on his head. A review of the facility's policy titled, "Procedure for Prevention of Patient abuse and mistreatment," revised 12/7/21, indicated the facility will provide a safe environment as free of injury to prevent Patient to Patient abuse by ensuring "each Patient admitted will be assessed for aggressive behavior or potential for striking out as being abusive to others (patient and staff), a plan of care will be implemented to address and prevent aggressive behaviors. The facility shall institute procedures that allows identification, correction, and intervention in situations in which abuse, neglect of patient is more likely to occur by identification of patients with potential for behavior symptoms and manifestations that may lead to conflict or anger through comprehensive assessment, care planning, and monitoring. Patients with behavioral symptoms and manifestations that may lead to conflict or anger are patients with history of aggressive behavior.