Health inspection·June 18, 2024

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation 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;

F609 483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. Nina Huynh 42223 The facility failed to ensure: 1. Protect Patient 1 from physical abuse (intentionally inflicting bodily injury such as slapping, hitting, kicking, and punching). On 4/17/2024, Patient 2 hit Patient 1 on the right cheek. 2. Report immediately not later than two hours of the allegation of physical abuse (intentionally inflicting bodily injury such as slapping, hitting, kicking, and punching) to the State Survey Agency (SSA) for Patient 1 in accordance with the facility's policy and procedure. These deficient practices have the potential for Patient 1 to have psychological distress. In addition, it placed Patient 1 and other patients in the facility risk for further abuse. A review of Patient 1's Admission Record indicated Patient 1, a 54 years old male was originally admitted on 11/6/2021 and was readmitted on 4/17/2023 with the following diagnosis of depressive disorder (involves a depressed mood or loss of pleasure or interest in activities for long periods of time) and epilepsy (a result of abnormal electrical brain activity, also known as seizure, kind of like an electrical storm inside your head). A review of Patient 1's History and Physical (H&P), dated 4/19/2023, indicated the patient is able to make decisions. A review of Patient 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 5/1/2024, indicated patient was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS also indicated patient required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or support trunk or limbs, but provides less than half the effort with oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and personal hygiene. Patient required substantial/ maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self and putting on/taking off footwear. A review of Patient 2's Admission Record indicated Patient 2, a 90 years old female was admitted on 8/22/2018 with the following diagnosis of depressive disorder (involves a depressed mood or loss of pleasure or interest in activities for long periods of time) and senile degeneration of brain (decreased ability to think, concentrate or remember). A review of Patient 2's H&P, dated 8/22/2023, indicated patient has poor memory. A review of Patient 2's MDS, dated 1/26/2024, indicated patient was severely impaired with cognitive skills for daily decision making. MDS also indicated patient required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Patient 2's Care Plan initiated on 1/1/2023, indicated Patient 2 tossed water on her roommate (not indicated) and demanding her jewelry. A review of Patient 2's progress notes, dated 4/1/2024 at 8:11 PM, indicated Patient 2 struck the charge nurse when Patient 2 was asked not to touch the medication chart. In addition, Patient 2's progress notes, dated 4/6/2024, at 12:27 PM, indicated Patient 2 was trying to exit the back door and when CNA approached Patient 2 to redirect, Patient 2 attempted to strike CNA. A review of Patient 2's Care Plan, dated 4/17/2024, indicated the patient had a physical altercation with Patient 1. During an interview on 5/6/2024 at 11:48 AM, Certified Nursing Assistant 1 (CNA 1) stated while coming out of Room A on 4/17/2024, CNA 1 witnessed Patient 2 hit Patient 1 on the right cheek. During an interview on 5/6/2024 at 1 PM, the Director of Nursing (DON) stated she tried to send the report on 4/17/2024 to the SSA but it was busy, so it did not go through. The DON also stated she have verified if the facsimile (fax, a telephone transmission, via a phone line, of a scanned copy of images and text printed on paper, transmitted between two people) report went through to make sure SSA was informed within the two (2)- hour time frame from when the incident between Patient 1 and 2 happened. During an interview on 5/6/2024 at 2:52 PM, Registered Nurse 1 (RN) 1 stated, Patient 2 intentionally hit Patient 1 on 4/17/2024. RN 1 also stated Patient 2 has moments when she gets agitated (fighting) and being aggressive towards others. During an interview on 5/6/2024 at 3:30 PM, the Director of Nursing (DON) stated Patient 2 had history (on 1/1/2023, 4/1/2024 and on 4/6/2024) of being aggressive towards other patients and staff. The DON stated Patient 2 did not have and should have a staff supervising or monitoring the patient for impulsive behavior or aggressive behavior to prevent further abuse to other patients or being aggressive towards other patient or staff. The DON also stated the incident on 4/17/2024 when Patient 2 hit Patient 1 on the right cheek could have bene prevented if Patient 2 was supervised by a staff. During an interview on 5/7/2024 at 9:09 AM, CNA 2 stated while she was passing out food trays on 4/17/2024, Patient 1 was wheeling himself to the room while passing by Patient 2. Patient 2 stopped Patient 1's wheelchair, saying bad words and hit Patient 1. CNA 2 also stated she was just there and witnessed the incident and no one was supervising or monitoring Patient 2 During an interview on 5/7/2024 at 9:39 AM, CNA 3 stated Patient 2 did not have a facility staff supervising or monitoring the patient to prevent patient from having an aggressive behavior towards another patient. During an interview on 5/7/2024 at 10:57 AM, the DON stated there was no new interventions done for Patient 2 except the order for the medications. During an observation on 5/7/2024 at 11:12 AM, Patient 1 and 2's room were one room apart. There was no staff observed in the nursing station or in the hallway of Patient 1 and 2's room. During an observation on 5/7/2024 at 12:22 PM, no staff was observed in the nursing station or in the hallway of Patient 1 and 2's room. During an observation on 5/7/2024 at 2:19 PM, no staff was observed in the nursing station or in the hallway of Patient 1 and 2's room. During an interview on 5/7/2024 at 3:10 PM, Administrator (ADM) stated report to the state agency should be within 2 hours from the alleged abuse or witnessed abused. The altercation between Patient 1 and 2 was not reported to SSA on 4/17/2024 within 2- hour from the incident. ADM stated, if the fax is busy, he would try it again until he got a confirmation stating the fax has been sent successfully. During an interview on 5/7/2024 at 4:34 PM, Administrator (ADM) stated patient did not have facility staff for Patient 2 to provide one to one (1:1, sitter, stays with the patient to provide constant monitoring for patient's safety) supervision to prevent further abuse. A review of the facility's Policy and Procedure titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised 9/2022, indicated upon receiving any allegations of abuse, the administrator is responsible for determining what actions (if any) are needed for the protection of patients. A review of the facility's Policy and Procedure titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised 9/2022, indicated the administrator or the individual making the allegation immediately (within 2 hours of an allegation involving abuse) reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility. The facility failed to ensure: 3. Protect Patient 1 from physical abuse (intentionally inflicting bodily injury such as slapping, hitting, kicking, and punching). On 4/17/2024, Patient 2 hit Patient 1 on the right cheek. 4. Report immediately not later than two hours of the allegation of physical abuse (intentionally inflicting bodily injury such as slapping, hitting, kicking, and punching) to the State Survey Agency (SSA) for Patient 1 in accordance with the facility's policy and procedure. These deficient practices have the potential for Patient 1 to have psychological distress. In addition, it placed Patient 1 and other patients in the facility risk for further abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1 and other patients.