Other·July 29, 2022

§ 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. 22 CCR § 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 7/10/2019 at 3 pm, the California Department of Public Health conducted an unannounced visit at the facility to investigate a Facility Reported Incident regarding quality of care and patient safety related to a patient-to-patient physical abuse. Patient 2 had a history of physically assaultive behavior (violent, physical actions which are likely to cause immediate physical harm or danger to an individual or others). On 7/9/2019 at 3:58 pm when Patient 1 attempted to squat on the floor, Patient 2 pushed Patient 1 to the floor and punched Patient 1 on the upper body, resulting in serious harm. The facility failed to: 1. Ensure Patient 1 was free from physical abuse by failing to protect Patient 1 from Patient 2 who had a known, documented history of physically assaultive behavior. 2. Follow its policy and procedure, “Identify Abuse and Abuse Prevention,” to prevent abuse. As a result of these failures, Patient 1 sustained a hip fracture (broken thighbone) and was transferred to a General Acute Care Hospital (GACH) Emergency Department (ED) on 7/10/2022 at 6:10 pm. Patient 1 underwent surgical intervention for the hip fracture and remained hospitalized until 8/21/2019. A review of Patient 2’s Care Plan, dated 5/1/2019, indicated the patient had a history of physically assaultive behavior. The care plan did not indicate specific goals nor interventions for the assaultive behavior. A review of Patient 1's Admission Record indicated the patient was admitted to the facility on 7/5/2016, with diagnoses that included schizoaffective disorder (a long-term mental illness that may change how a person thinks, feels, and acts around others), insomnia (difficulty in sleeping), psychoactive (chemical substance that acts primarily upon the central nervous system where it changes the brain function, resulting in temporary changes in perception, mood, consciousness and behavior) and substance dependence. A review of Patient 1’s Minimum Data Set (MDS-care screening tool) assessment, dated 7/2/2019, indicated Patient 1 was able to make himself understood and had the ability to understand others. The MDS indicated Patient 1 was independent for walking and personal hygiene. A review of the facility's Staff Event Report, dated 7/9/2019, indicated Patient 2 punched Patient 1 in the face on 7/9/2019, at approximately 4 pm. During concurrent observation and interview on 7/10/2019, at 3:30 pm, Patient 1 was observed walking to the Administrator’s office for an interview. Patient 1 was having difficulty walking assisted by three staff members (2 staff on each side and one staff at the back). Patient 1 stated, "Somebody hit me, and I just couldn’t walk." On 7/10/2010, at 3:10 pm, the facility provided a video recording dated 7/9/2019 with the following events: At 3:57:07 pm, Patient 1 was ambulating without difficulty towards the West front door (facility’s hallway). At 3:58:06 pm, Patient 2 pushed Patient 1 to the ground, and punched Patient 1's upper body causing Patient 1 to lay down on his left side and covering his face and head. At 3:58:39 pm, Patient 1 was ambulating alone towards a nearby chair and was observed limping. During an interview on 7/29/2019, at 3 pm, Licensed Vocational Nurse 1 (LVN 1) stated she performed Patient 1's assessment on 7/9/2019, at 4 pm, when she was informed Patient 1 complained of not being able to walk. During an interview on 7/10/2019, at 3:15 pm, the Program Director stated Patient 1 “Started to have difficulty in walking today at 12:30 pm, and he will be seen by the physician later today." During an interview on 7/10/2019, at 4 pm, Patient 1’s Physician (MD 1) stated Patient 1 complained of left thigh pain. The physician stated during his examination on [date and time], Patient 1 had full range of motion (measurement of movement around a specific joint or body part freely) on all extremities and would be monitored until the following morning. MD 1 stated he would continue to monitor Patient 1 that night and would transfer the patient to the hospital the next day if Patient 1’s condition did not improve. During a telephone interview on 7/11/2019, at 11 am, the Director of Nursing (DON) stated the facility sent Patient 1 to the ED on 7/10/2019, at 6 pm. The DON stated Patient 1 was admitted the GACH due to a transcervical fracture involving the left femoral neck (broken thigh bone just below the ball-and-socket hip joint). A review of Patient 1’s ED Physician’s Note (GACH Record), indicated Patient 1 was evaluated in the ED on 7/10/2019 at 6:39 pm. The notes indicated Patient 1 was unable to walk secondary to pain. The notes indicated Patient 1's left lower extremity was externally rotated (thigh and knee rotate outward, away from the body) and shortened and the GACH admitted Patient 1 for medical/surgical management. A review of Patient 1’s GACH Discharge Summary, dated 7/11/2019, indicated Patient 1 underwent and open reduction internal fixation (a surgery to fix severely broken bones) of the left femoral neck fracture. The notes indicated Patient 1 was discharged on 8/21/2021. A review of the facility’s policy and procedure titled “Identify Abuse and Abuse Prevention,” revised on in 7/2019, indicated the facility will not condone any form of patient abuse. The policy indicated for facility’s staff to aid in abuse prevention. The facility failed to: 1. Ensure Patient 1 was free from physical abuse by failing to protect Patient 1 from Patient 2 who had a known, documented history of physically assaultive behavior. 2. Follow its policy and procedure, “Identify Abuse and Abuse Prevention,” to prevent abuse. As a result of these failures, Patient 1 sustained a hip fracture (broken thighbone) and was transferred to a General Acute Care Hospital (GACH) Emergency Department (ED) on 7/10/2022 at 6:10 pm. Patient 1 underwent surgical intervention for the hip fracture and remained hospitalized until 8/21/2019. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.