Health inspection·April 5, 2024

Code of Federal Regulations, Title 42, §483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation §483.12(a)(1) The resident has the right to be free from abuse, neglect, misappropriation of resident 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 resident’s medical symptoms. California Code of Regulations, Title 22, § 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. California Code of Regulations, Title 22, § 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. California Code of Regulations, Title 22, § 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 3/21/2024 at 7:30 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate Facility Reported Incidents regarding resident abuse. As a result of the investigation, the CDPH determined that the facility failed to follow its abuse policy tittle, "Abuse Prohibition," and prevent Certified Nurse Assistant 1 (CNA 1) from cussing and throwing CNA 1’s hand up at Resident 2. These failures violated Resident 2’ right and had the potential to result in a negative impact on Resident 2's psychosocial well-being. A review of Resident 2's Admission Record (AR) indicated the facility initially admitted Resident 2, a 50-year-old male to the facility on 2/28/2023 with multiple diagnoses including schizophrenia (serious mental illness characterized by loss of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). A review of Resident 2's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/15/2023, indicated Resident 2 had moderate impairment in cognition (ability to acquire knowledge and understand information). The MDS indicated Resident 2 was independent with self-care activities and independent in terms of mobility (ability to move). A review of Resident 2's Physician Narrative History and Physical (H&P) dated 3/7/2023, indicated Resident 2 was alert and oriented. A review of Resident 2's eINTERACT Change in Condition Evaluation (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), dated 2/15/2024, indicated Licensed Psychiatric Technician 1 (LPT 1) notified Resident 2's primary physician and responsible party of Resident 2 being "involved [in] a verbal altercation with staff." A review of Resident 2's Progress Note (PN) dated 2/15/2024 timed at 11:55 a.m. indicated, during the smoke break [on 2/15/2024], staff [unidentified] overheard male staff yelling and cussing at resident [Resident 2] regarding morning coffee break. Female staff redirected male staff from engaging [in] offensive language towards male resident [Resident 2]. Charge nurse removed male staff from the area. Resident 2 observed walking towards Resident 2’s room. The PC [program counselor] checked in with Resident 2, and Resident 2 stated, "That male staff was cussing and throwing his hand up at me. I was just trying to go back to my room." A review of the Witness Interview Record (WIR) dated 2/15/2024, indicated Resident 2 was interviewed by facility [staff]. The WIR indicated Resident 2 was walking back to Resident 2's room when CNA 1 stopped Resident 2 and told Resident 2 he could not take the coffee to Resident 2's room. The WIR indicated CNA 1 "started cussing at me [Resident 2] and I [Resident 2] cussed back." The WIR indicated CNA 1 "was throwing his hands up at me [Resident 2]." A review of the Corrective Action Memo (CAM) for CNA 1, dated 2/19/2024 indicated CNA 1 was terminated from the facility due to CNA 1 was, " yelling at a resident in a threatening manner and has used profanity." During an interview on 2/21/2024 at 10:15 a.m., Resident 2 stated CNA 1 was "screaming at me." Resident 2 stated, "He hollered at me for no reason." During a telephone interview on 2/22/2024 at 10:06 a.m., CNA 1 stated during the coffee break in the courtyard on 2/15/2024, Resident 2 was "saying disrespectful things" and was trying to go back to Resident 2's room. CNA 1 stated Resident 2 stated, "I don't care about what you say. I own you. You belong to me." CNA 1 stated he had an "outburst" and stated to Resident 2, "Say that again. Say that to my face." CNA 1 stated CNA 1 knew how Resident 2 behaved, and CNA 1 should have "ignored his words." During an interview on 2/22/2024 at 10:37 a.m., LPT 1 stated on 2/15/2024, during a coffee break in the courtyard, LPT 1 heard Resident 2 and CNA 1 "yelling" while LPT 1 was at the nurses' station. LPT 1 stated CNA 1 looked "upset," so LPT 1 redirected CNA 1 away from the situation. During an interview on 2/22/2024 at 11:05 a.m., CNA 2 stated on 2/15/2024, CNA 2 was with LPT 1 in the nurses' station when CNA 2 heard "raised voices." CNA 2 stated CNA 2 saw Resident 2 "retreating towards the Center Door to the West Unit" when CNA 2 saw CNA 1 "charging [towards Resident 2] with his right fist in the air and saying, 'Don't try that shit again.'" CNA 2 stated LPT 1 asked CNA 1 to go to the nurses' station to "calm down." CNA 2 stated Resident 2 went back to Resident 2's room to watch the television. CNA 2 stated Resident 2 stated Resident 2 did not know why CNA 1 was "behaving that way." During an interview on 2/22/2024 at 11:24 a.m., CNA 3 stated on 2/15/2024, CNA 3 and CNA 1 started serving coffee to the residents at 9 a.m. CNA 3 stated while serving coffee to the residents, CNA 3 witnessed CNA 1 going towards the grass area in the courtyard to argue with Resident 2. CNA 3 stated CNA 3 did not hear what they were arguing about. CNA 3 stated CNA 3 witnessed Resident 2 walking away from the argument as CNA 3 attempted to call CNA 1 to continue serving coffee to the other residents in line, but CNA 1 continued to follow Resident 2 until the argument, "started getting louder." CNA 3 stated, "They [Resident 2 and CNA 1] were both cussing." CNA 3 stated CNA 1 should not have let the situation escalate and should have instead informed the programming staff and/or Charge Nurse of Resident 2's behavior. During an interview on 2/22/2024 at 1:18 p.m., the Program Director (PD) stated if a resident (in general) was noncompliant with the facility rules, the staff must not further escalate the situation, because chasing after the resident or raising one's voice would not be effective. The PD stated unless the resident was in danger, the staff must give the resident "some space" and remind the resident about following the facility rules later. The PD stated the potential outcomes of staff abuse on residents include "triggering past trauma events" or "increased behavioral symptoms." The PD stated Resident 2 did not have any observed increased behavioral symptoms. During a review of the facility's policy and procedures (P&P), titled "Abuse Prohibition," dated 2/23/2021, the P&P indicated the following: 1. The facility prohibit abuse, mistreatment, neglect, and exploitation of all residents. 2. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. 3. Willful is defined as the individual acted deliberately, not that the individual must have intended to inflict injury or harm. 4. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples include threats of harm, saying things to frighten a resident. 5. Mental abuse includes any verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. 6. Mistreatment is defined as inappropriate treatment or exploitation of a resident. The facility failed to follow its abuse policy tittle, "Abuse Prohibition," and prevent CNA 1 from cussing and throwing CNA 1’s hand up at Resident 2. These failures violated Resident 2’ right and had the potential to result in a negative impact on Resident 2's psychosocial well-being. These violations jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2.