Health inspection·May 17, 2024

On 4/4/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding quality of care and resident abuse. As a result of the investigation, the CPDH determined the facility failed to ensure Resident 5 was free from physical restraints for use of convenience by failing to ensure Certified Nurse Assistant (CNA) 1 did not tie the bedsheet/fitted sheet to the grab bar and keep Resident 5's arms under the fitted sheet to prevent Resident 5 from moving Resident 5's arms. This failure violated Resident 5's right to be from physical restraints and had the potential for Resident 5 to suffer psychosocial (mental, emotional, social, and spiritual effects) harm, and/or physical injury. A review of Resident 5’s Admission Record indicated the facility admitted Resident 5, a 76-year-old male, on 2/27/24, with diagnoses of Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and history of falling. A review of Resident 5's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 3/2/24, indicated Resident 5 had severely impaired cognition. The MDS indicated, Resident 5 required substantial/maximal assistance for eating, oral hygiene, and toileting hygiene. The MDS indicated, Resident 5 required substantial/maximal assistance for sitting to standing. A review of Resident 5's Physician's Orders (PO) dated 3/19/24, indicated an order for staff to monitor Resident 5's episodes of anxiety manifested by (m/b) periods of restlessness and attempting to pull out Resident 5’s foley catheter (a device that drained urine from the urinary bladder into a collection bag outside of the body) and to tally with hashmarks on the Medication Administration Record (MAR) every shift. A review of Resident 5's MAR dated 3/19/24 to 3/31/24, indicated for staff to monitor Resident 5's episodes of anxiety m/b periods of restlessness and attempting to pull out the foley catheter and to tally with hashmarks on the MAR every shift. The MAR indicated Resident 5 did not have any episodes of anxiety m/b periods of restlessness and attempting to pull out the foley catheter on 3/30/24 during the 7 am to 3 pm, 3 pm to 11 pm, and 11 pm to 7 am shifts. A review of Resident 5's Progress Notes (PN) dated on 3/30/24, timed at 12 pm, written by Licensed Vocational Nurse (LVN) 5, indicated CNA 2, CNA 3, and LVN 6 reported that a fitted sheet was wrapped into the grab bar causing Resident 5 to have limited movement. The PN indicated CNA 2 and CNA 3 removed the fitted sheet from the grab bar immediately. A review of Resident 5's PN dated on 3/30/24, timed at 2:30 pm, written by Registered Nurse 2 (RN 2), indicated RN 2 received report from LVN 6 and CNA 2 that Resident 5 was noted with limited mobility due to a fitted sheet observed to be wrapped around the grab bars. A review of Resident 5's Care Plan (CP) titled, "Alleged abuse (fitted sheet wrapped on the resident's grab bar causing limited movement)," dated 3/30/24, indicated the facility staff would anticipate and meet Resident 5's needs and for staff to keep the call light in reach for assistance at all times. A review of Resident 5's PN dated on 3/31/24, timed at 11:49 am, written by RN 2, indicated RN 2 re-assessed Resident 5 due to being found with a fitted sheet wrapped over Resident 5 and wrapped around the grab bars suspected to limit Resident 5's mobility due to Resident 5's tendency to become restless. During an interview on 4/5/24 at 11:15 am, CNA 2 stated CNA 2 was walking down the hall towards Station 2 to get coffee for another resident when CNA 3 called CNA 2 to come into Resident 5's room. CNA 2 stated Resident 5 was awake and sitting upright with Resident 5's legs elevated. CNA 2 stated Resident 5's arms were by Resident 5's side under the fitted sheet. CNA 2 stated the fitted sheet was tied in a knot on Resident 5's right side of the grab bar. CNA 2 stated the fitted sheet was wrapped up and over Resident 5's left side grab bar. CNA 2 stated the fitted sheet was fitted over the mattress at the foot of Resident 5's bed. CNA 2 stated there were two blankets on top of Resident 5 over the fitted sheet. CNA 2 stated that the blue blanket was a regular blanket and the white one was a lighter blanket. CNA 2 stated CNA 2 told CNA 3 that "it should not be like this" and to report the situation. CNA 2 stated CNA 3 reported “it” to RN 1. CNA 2 called for LVN 6 to come into Resident 5's room. CNA 2 stated while LVN 6 was talking to CNA 2, CNA 2 removed the fitted sheet on Resident 5. During a phone interview on 4/5/25 at 12:13 pm, CNA 3 stated CNA 3 found a fitted sheet on top of Resident 5's grab bar with a blue blanket on top. CNA 3 stated the fitted sheet was tied on Resident 5's right grab bar and wrapped in Resident 5's left grab bar. CNA 3 stated the bottom of the fitted sheet was on Resident 5's bed and covered with a blanket. CNA 3 stated CNA 2 released the fitted sheet on Resident 5's right side and went to call LVN 6. CNA 3 stated LVN 6 and RN 2 came into Resident 5's room and checked Resident 5. During an interview on 4/5/24 at 12:30 pm, LVN 6 stated CNA 2 alerted her to come into Resident 5's room. LVN 6 stated Resident 5 was sitting up in bed. LVN 6 stated Resident 5's arms were underneath a blanket. LVN 6 stated the top of the fitted sheet was tied onto Resident 5's right railing and wrapped around the left railing. LVN 6 stated the sides of the fitted sheet were tucked in and fitted around the bed on all sides. LVN 6 stated it was a fitted sheet and Resident 5 was inside it. LVN 6 stated as LVN 6 was coming into Resident 5's room, CNA 2 was undoing the knot. LVN 6 stated LVN 6 unwrapped the sheet and uncovered Resident 5 so that he had free movement. LVN 6 stated there were two blankets on top of the fitted sheet. LVN 6 stated Resident 5 was covered by the two blankets, exposing the tied blankets to the railing. LVN 6 stated once LVN 6 untied the sheet, Resident 5 was able to move Resident 5's arms. LVN 6 stated Resident 5 could move Resident 5's arms minimally while Resident 5 was wrapped under the fitted sheet. LVN 6 stated Resident 5 was moving under the sheet but there was resistance when Resident 5 moved Resident 5's arms. During a phone interview with CNA 1 on 4/5/24 at 3 pm, CNA 1 stated at around 1:30 am, Resident 5 was awake and trying to pull Resident 5's catheter out. CNA 1 stated CNA 1 informed Resident 5 not to pull the catheter because Resident 5 was going to hurt himself. CNA 1 stated Resident 5 stopped and CNA 1 covered Resident 5 with a blue blanket and Resident 5 calmed down. CNA 1 stated CNA 1 put the blankets around Resident 5's rails around 4 am. CNA 1 stated CNA 1 "did it" so that Resident 5 would not hurt himself. CNA 1 stated Resident 5 was trying to get up and CNA 1 put the fitted sheet on the mattress as if Resident 5 was being hugged and that Resident 5 stayed calm. CNA 1 stated CNA 1 was not going to tie the fitted sheet but because Resident 5 was trying to get up, CNA 1 "tied it." CNA 1 stated it was a busy period between 4 am to 6 am because CNA 1 answered call lights. CNA 1 stated CNA 1 went back to Resident 5's room and Resident 5 was asleep and calm, so CNA 1 went to attend to other residents. CNA 1 stated the facility made CNA 1 aware of the allegations and that CNA 1 was suspended immediately. CNA 1 stated the facility’s Director of Staff Development and Administrator asked if CNA 1 knew what CNA 1 did to Resident 5 was considered abuse. CNA 1 stated that CNA 1 regretted doing what CNA 1 did and that was not how CNA 1 worked. CNA 1 stated CNA 1 learned to communicate with the charge nurses to determine if it was safe to do certain interventions for a resident. A review of the facility's policy and procedure (PP) titled, "Abuse Prevention Program," revised in 12/2016, indicated the facility's residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The PP indicated this included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The PP indicated the administration protected their residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A review of the facility's PP titled, "Use of Restraints," revised in 12/2007, the PP indicated physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricted freedom of movement or restricted normal access to one's body. The facility failed to ensure Resident 5 was free from physical restraints for use of convenience by failing to ensure CNA 1 did not tie the bedsheet/fitted sheet to the grab bar and keep Resident 5's arms under the fitted sheet to prevent Resident 5 from moving Resident 5's arms. This failure violated Resident 5's right to be from physical restraints and had the potential for Resident 5 to suffer psychosocial harm and/or physical injury. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 5.