Other·December 21, 2022

F689 §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. T22 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. T22 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 10/5/2022 at 11:15 am, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility Reported Incident (FRI) regarding patient-to-patient abuse. On 9/26/2022, the Facility submitted a FRI to the CDPH which indicated Patients 1 and 2 had a physical altercation outside the facility’s patio on 9/25/2022. As a result of the investigation, the CDPH determined the facility failed to follow its policy on “Safety and Supervision of Residents,” for Patients 1 and 2 by failing to: 1. Provide supervision at the facility’s patio for Patients 1 and 2 who had a history of mental illness and behavioral problems, to prevent Patients 1 and 2 from physically assaulting each other with an approximated nine-inch metal object used as a deadly weapon on 9/25/2022 at 10 pm. As a result of these deficient practices, on 9/25/2022 at 10 pm, at the patio, Patients 1 and 2 stabbed each other with the same object causing puncture wounds (an injury that causes a deep wound or cut) on both of Patient 1’s and 2’s bodies. a. A review of Patient 1's Admission Record indicated the facility admitted a sixty-two-year-old-male on 4/28/2022, with diagnoses including generalized muscle weakness, and bipolar disorder (a mental health condition that causes extreme mood swings). A review of Patient 1's undated Initial History and Physical, indicated the patient had the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/5/2022, indicated the patient was able to make his needs known and had moderately impaired cognition (appropriate thinking and understanding, ability to make decisions). The MDS indicated the patient required supervision in walking in the corridor, locomotion off the unit (how the patient moves to and returns from off-unit locations). A review of Patient 1's untitled Care Plan, undated, indicated the patient had limited physical mobility related to weakness. The care plan interventions included staff to provide extensive assistance to walk daily as needed and supervision for locomotion using wheelchair. A review of Patient 1's untitled Care Plan, undated, indicated the patient had impaired cognitive function or impaired thought process related to short term memory loss and forgetfulness. The care plan interventions included to cue, orient, and supervise the patient as needed. A review of Patient 1's Change in Condition (COC) Evaluation, dated 9/25/2022, timed at 10 pm, indicated Patient 1 had physical altercation with Patient 2. The COC evaluation indicated Patient 1 sustained an abrasion (skin open wound) on the mid-chest area. A review of Patient 1's Licensed Progress Note, dated 9/26/2022, timed at 1 am, indicated Registered Nurse 1 (RN 1) witnessed Patient 1 pushed Patient 2 due to Patient 2 trying to stab Patient 1 with no provocation. The notes indicated RN 1 and Licensed Vocational Nurse 3 (LVN 3) intervened to deescalate the situation. A review of Patient 1's Police Incident Report dated 9/26/2022, indicated Patient 1 stated on 9/25/2022, at approximately 11 pm, Patient 1 was sitting outside the patio area when Patient 2 approached him in an aggressive manner and began to stab him approximately four times. The report indicated Patient 1's statement indicated Patient 2 was holding an approximated 10-inch metal pick with a sharp pointed tip on his right hand. Patient 1's statement indicated Patient 2 made stabbing motion towards him by holding the metal pick in his right hand and thrusted it forward. Patient 1's statement indicated Patient 2 was able to stab Patient 1 once on the chest area. The report indicated Patient 1 was able to protect himself by blocking Patient 2's attempts to stab him further by using his arms. The report indicated Patient 1 grabbed the metal pick from Patient 2 and threw it over a fence located north of the patient's position. The report indicated Patient 2 grabbed a cigarette disposal container located in the patio, swung it at him, and struck his shoulder approximately four times. The report indicated Patient 2 dropped the cigarette disposal container and proceeded to grab his wheelchair. The report indicated Patient 2 began to push the wheelchair towards Patient 1 in an attempt to assault Patient 1 with it. The report indicated Patient 1's statement indicated at this point facility staff walked in and separated them. b. A review of Patient 2's Admission Record indicated the facility admitted a sixty-one-year-old-male on 7/16/2020 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), and unspecified psychosis (a condition that affects the way the brain processes information causing to lose touch with reality) not due to substance or known physiological (consistent with the normal functioning) condition. A review of Patient 2's MDS dated 7/26/2022, indicated the patient was able to make his needs known and had moderately impaired cognition. The MDS indicated the patient had inattention, disorganized thinking, altered level of consciousness (not as awake, alert, or able to understand or react as you are normally) and mood symptoms. The MDS indicated the patient required supervision with transfers, walking in the room, locomotion on and off the unit and personal hygiene. The MDS indicated the patient normally used a walker (device that gives additional support to maintain balance or stability while walking), and a wheelchair for mobility. A review of Patient 2' untitled Care Plan, dated 10/29/2020, indicated the patient was at risk for fracture (broken bone) injury due to disease process. The care plan interventions included to assist the patient with activities of daily living and always monitor patient’s safety. A review of Patient 2's Initial History and Physical dated 8/9/2021, indicated the patient had the capacity to understand and make decisions. A review of Patient 2's untitled Care Plan dated 5/5/2022, indicated the patient had the potential to be verbally aggressive toward staff, patients, and visitors related to poor impulse control, fabricating (to produce something false) stories, and delusions (false belief) of working with the Department of Justice (the United States federal department responsible for enforcing federal laws) and everyone was after him to kill him because of that. The care plan interventions included for the nursing staff to intervene when the patient became agitated, guide away from source of distress, and monitor behavior and document observed behavior and attempted interventions. A review of Patient 2's Licensed Progress Note dated 9/25/2022, timed at 9:50 pm, indicated at 9:30 pm (on 9/25/2022), LVN 4 noticed Patient 2 was walking around the hallway, talking to himself regarding medical fraud and that something big was going to happen because he was a cop and involved in a department. The note indicated LVN 4 asked Patient 2 what he meant but the patient refused to answer and kept walking in the hallway. The note indicated the patient was not using his wheelchair like usual. The note indicated the patient stated, "I don't need that right now." A review of Patient 2's Licensed Progress Note, dated 9/25/2022, timed at 9:50 pm, indicated at approximately 9:50 pm (on 9/25/2022), RN 1 heard a commotion and decided to check the patio. The note indicated RN 1 went outside the patio and saw Patient 1 pushed Patient 2 to the ground facing up. The note indicated RN 1 got in between the patients to deescalate the situation. The note indicated RN 1 saw LVN 3 and told LVN 3 to help Patient 2. The note indicated Patients 1 and 2 were separated. RN 1 asked Patient 1 what happened. The notes indicated Patient 1 stated Patient 2 tried to stab him. The notes indicated Patient 1's shirt had a hole and the patient had a red non-bleeding puncture site on the abdomen. The note indicated Patient 2 had two wounds on both arms and were cleaned per facility protocol. The note indicated at 10 pm, the Administrator (ADM), Director of Nursing (DON), Ombudsman (an official appointed to investigate individuals' complaints against maladministration), Department of Public Health, Sheriff's Department, and the patients' physician were notified. The notes indicated at 10:30 pm, the Sheriff's Department came and conducted its investigation. A review of Patient 2's Police Incident Report dated 9/26/2022, indicated (on 9/25/2022) Patient 2 went outside the patio area with his wheelchair. The report indicated Patient 1 approached him and shouted, "You're dead I'm going to kill you." The report indicated Patient 2 stood up from his wheelchair and Patient 1 walked up to him. The report indicated Patient 1 pushed him with his right hand. The report indicated Patient 2 was able to maintain his balance and walked behind his wheelchair to protect himself from Patient 1's attack. The report indicated Patient 1 then grabbed the wheelchair and threw it to the side and said, "You got nothing." The report indicated Patient 1 began to poke him with an approximated eight-inch long and quarter inch thick shiny metal object. The report indicated Patient 1 stabbed him approximately four times on the left side of his body. The report indicated Patient 2 then grabbed the cigarette dispense container in the patio like a baseball bat and used it to defend himself by striking Patient 1 approximately four times on his left shoulder. The report indicated Patient 2's statement indicated Patient 1 then pushed Patient 2 on his chest with both hands causing Patient 2 to lose balance and fall backwards onto the ground facing up. The report indicated as Patient 2 was on the ground, Patient 1 stood approximately seven feet away at this point, two nurses arrived at their location and kept them separated from each other. A review of RN 1's statement from the Police Report dated 9/26/2022, indicated RN 1 was walking near the door that led to the outside patio when she heard a commotion coming from the outdoor patio. RN 1 went to check what was going on and saw Patients 1 and 2 standing and facing each other. RN 1's statement indicated Patient 1 pushed Patient 2 in an aggressive manner with both his hands on the chest area. RN 1's statement indicated she saw Patient 2 fall backwards onto the ground on his back, facing up. RN 1 statement indicated she stepped in between the patients and was able to keep them separated. RN 1 instructed another staff (LVN 3) to come to the patio and assist with the incident. RN 1's statement indicated she evaluated Patient 1 and saw a circular wound on the center of the patient's chest. LVN 3 assisted RN 1 and evaluated Patient 2 who was still on the ground. RN 1 statement indicated after the incident, she checked the immediate area of the incident and located a metal pick and wooden cross on the floor. A review of the Police Incident Report dated 9/26/2022, indicated Patient 2 sustained a circular puncture wound on the left and right forearms, redness, and a bruise on the left elbow, four puncture wounds on the left side of the torso, puncture wound on the left middle finger, and a scratch on the center of the chest. The report indicated the facility staff treated Patient 2 for his injuries. The report indicated Patient 1 was determined to be the dominant aggressor in the assault based on Patient 2's statements coupled with his visible injuries and RN 1's statements. Patient 1 was placed under arrest for assault with a deadly weapon and was transported to the police station. A review of the facility's conclusion of investigation dated 9/28/2022, indicated the facility determined that the incident happened, and Patient 1 was taken into custody by the Sheriff's Department. The facility's investigation indicated due to conflicting stories and lack of witnesses, the facility was unable to determine who initiated the incident and how the event transpired. The facility provided separation of patients along with treatment and increased supervision of the patients. During an observation and concurrent interview on 10/5/2022 at 11:31 am, Patient 2 was sitting in his wheelchair inside his room. Patient 2 did not allow Surveyor 1 to enter his room and preferred not to answer any questions. Patient 2 yelled, cursed, and stated, "I don't want to talk to you, you [derogatory] -. Go away from me and never come back." During an interview on 10/5/2022 at 12:26 pm, LVN 2 stated Patient 2 was verbally aggressive to the staff, but never struck the staff. LVN 2 stated Patient 2 was delusional and believed that the government was after him. LVN 2 stated Patient 2's physician ordered a psychiatry consult, but Patient 2 refused and stated he was not crazy. LVN 2 stated Patient 2 had a physician's order to go to the hospital for evaluation after the incident, but he refused to go. LVN 2 stated the facility allowed ambulatory alert and oriented patients to go out to the patio at night. During a telephone interview on 10/5/2022 at 2:07 pm, LVN 3 stated she was passing medications when she heard the commotion in the patio on 9/25/2022. LVN 3 stated she saw RN 1 in the patio separating Patients 1 and 2 and Patient 2 was on the floor. LVN 3 stated she assisted Patient 2 and took the patient in the nursing station. LVN 3 stated per Patient 2, he followed Patient 1 to the patio. LVN 3 stated Patient 2 claimed he was a police officer and was checking on Patient 1. LVN 3 stated Patient 2 sustained an abrasion on the right arm and refused to go to the hospital for an evaluation. During a telephone interview on 10/28/2022 at 4:01 pm, RN 1 stated around 10 pm (on 9/25/2022), she heard a noise and went outside the patio and saw Patient 1 pushing Patient 2 to the ground. RN 1 stated she immediately got in between Patients1 and 2. RN 1 called LVN 3 who was in another patient's room with a sliding door that led to the patio. RN 1 stated LVN 3 came and helped Patient 2 and took him inside the facility. RN 1 stated when she asked Patient 1 what happened, Patient 1 stated that Patient 2 went outside and started telling him stuff. Patient 1 told RN 1 that Patient 2 came at him and tried to stab him. RN 1 stated Patient 1 showed her the hole on his shirt. Patient 1 then lifted his shirt and showed RN 1 a small puncture wound on his abdomen that was not bleeding. RN 1 stated she found a metal object in the patio area that looked like a very thin silver rod and a cross. RN 1 stated she was not certain if the metal object and the cross were supposed to be attached together. RN 1 stated she had never seen Patient 1 or Patient 2 with that metal object and cross prior to the incident. RN 1 stated she checked on Patient 2 and asked him what happened. Patient 2 told RN 1 that he was with the Department of Justice and caught Patient 1 doing medical fraud. RN 1 stated per Patient 2, Patient 1 attacked him and stabbed him with something. RN 1 stated Patient 2 had a dime-sized bleeding wound on both of his arms. RN 1 stated the night of the incident, Patient 2 seemed off. Patient 2 was going around the whole facility, asking for a certain person who we did not know about. RN 1 stated Patient 2 seemed like he was going around the facility looking for that person. RN 1 stated patients were allowed to go to the patio at any time with or without supervision. RN 1 stated supervision and monitoring was mainly fo