Health inspection·October 26, 2023

REGULATORY VIOLATIONS: Title 22, California Code of Regulations 72515 – 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. 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. 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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. Title 42 Code of Federal Regulations: §483.12 Freedom from Abuse, Neglect, and Exploitation 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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; On 9/12/2023 at 9:35 A.M., an unannounced visit was made by the California Department of Public Health (CDPH) to the facility to investigate two facility reports regarding patient abuse. The facility failed to protect Patient 2 from physical abuse against Patient 1, who had a known history of physical aggression toward staff and other patients by failing to: 1. Supervise Patient 1 to prevent Patient 1 from hitting Patient 2 on 8/27/2023, during the 3 PM to 11 PM shift, after Patient 1 had change of condition (COC) manifested by increased verbal/physical aggression and striking out during the 7 AM to 3 PM shift. 2. Ensure that a care plan was initiated when Patient 1 had a change of condition manifested by increased in verbal and physical aggression on 8/27/2023. 3. Follow the facility’s policy and procedure (P&P) titled, “Abuse Prevention, Screening, & Training Program,” that indicated the facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of Patient property and/or mistreatment is more likely to occur. These failures resulted in Patient 1 striking out at Patient 2 by hitting his left cheek. Patient 2 developed altered level of consciousness (ALOC) and was transferred to the general acute care hospital (GACH) for evaluation via 911 emergency services. A review of the Face Sheet (admission record) indicated a 30 year old male patient, Patient 1 was initially admitted to the facility on 1/31/2023, with diagnoses including schizoaffective ( a mental illness that can affect your thoughts, mood and behavior) disorder, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and auditory hallucinations (perceptual experiences in the absence of real external sensory stimuli). A review of Patient 1’s Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 8/4/2023, indicated Patient 1’s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were not intact. The MDS indicated Patient 1 required supervision with bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, and eating. The MDS indicated Patient 1 required limited assistance from staff for dressing, toilet use, and personal hygiene. A review of Patient 1’s Change of Condition (COC) note, dated 8/27/2023, timed at 10:40 am (morning shift), indicated Patient 1 had an increased verbal and physical aggression. A review of Patient 1’s COC note, dated 8/27/2023, timed at 4 pm (afternoon shift), indicated Patient 1 had episodes of responding to internal stimuli that leads to striking at another Patient out. During a review of the Face Sheet, indicated a male 61-year-old patient, Patient 2 was admitted to the facility on 7/10/23, with diagnosis including major depressive disorder, schizoaffective, and hypertension (high blood pressure). During a review of Patient 2’s MDS, dated 8/17/2023, the MDS indicated Patient 2’s cognitive skills was impaired, and required staff supervision for bed mobility, transfers, walk in room, walk in corridor, locomotion in unit, locomotion off unit, and eating. The MDS indicated Patient 2 required extensive assistance with dressing, toilet use and personal hygiene. A review of Patient 2’s Change of Condition (COC) note, dated 8/27/2023, timed at 4:10 pm, indicated Patient 2 was struck out on the left cheek which resulted in altered mental status, unequal grip strength, generalized weakness noted, pupil reactive to light, verbally responsive with slurred speech. The COC indicated Patient 2 was transferred to the GACH via 911 at around 4:10 pm. A review of Patient 2’s GACH Emergency Department (ED) records discharge instructions dated 8/27/2023 timed at 8:11 pm, indicated ED visit start date of 8/27/2023, and discharged the same date indicated Patient 2’s diagnosis of facial injury. A review of Patient 1’s care plan titled “The Patient with episode of responding to internal stimuli which lead to physical aggression and struck out another patient,” initiated on 8/27/2023 (no time), included the following interventions: 1. Assess and address for contributing sensory deficits. 2. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. 3. Immediately separated Patient away from another Patient. 4. Informed physician of incident. 5. Informed responsible party of incident. 6. Placed on one-on-one supervision and safety 7. Transfer to GACH as ordered 8. When the patient becomes agitated: Intervene before agitation escalates; Guide away from source of distress... On 9/12/2023 at 1:30 pm, during a concurrent interview and record review of Patient 1’s care plan titled “The Patient with episode of responding to internal stimuli which lead to physical aggression and struck out another Patient,” with LVN 1, LVN 1 stated that the care plan was initiated when Patient 1 struck Patient 2 during the afternoon shift of 8/27/2023. LVN 1 stated that there was no care plan initiated when Patient 1 had a COC during the morning shift (7 am to 3 pm shift) of 8/27/2023 when Patient 1 had an increased in verbal and physical aggression towards others. LVN 1 stated she forgot to develop the care plan during the morning shift when it happened. LVN 1 stated she initiated the COC but did not initiate a care plan to keep track of what interventions to implement for Patient 1’s COC. LVN 1 stated that if there was a care plan, the facility staff would have interventions to follow to avoid further verbal/physical aggression of Patient 1 towards others (Patient 2). LVN 1 added that on 8/27/2023, Patient 2 was “cussing” (swearing) in the hallway and patio while pacing, more verbally aggressive/threatening staff than usual and possibly upset about buying candy/food. LVN 1 stated Patient 2 was yelling and screaming. LVN 1 stated that Patient 2 usually talks a lot but on 8/27/2023, during the morning shift, Patient 2 was verbally threatening others as well. During an interview on 9/12/2023 at 2:40 pm with Certified Nurse Assistant (CNA) 1, CNA 1 recalled Patient 2 had been going in and out of the patio more often than usual and had episodes of screaming at others while walking during the morning of 8/27/2023. During an interview on 9/12/23 at 3:35 pm with Registered Nurse (RN) 1, RN 1 stated that on 8/27/2023, during the 3 PM to 11 PM shift, she was standing next to Patient 2 in the hallway and saw when Patient 1 paced around and struck Patient 2 without provocation (an action or speech that makes someone annoyed or angry). RN 1 stated that Patient 2 was hit on his left cheek that resulted in altered mental status and had altered level of consciousness. RN 1 stated that 911 emergency services was called for Patient 2 and was transferred out of the facility to GACH for further evaluation. During an interview on 9/12/23 at 4:25 pm with the Director of Nursing (DON), the DON was unable to provide documented evidence of a care plan developed for Patient 1’s change of behavior on 8/27/2023 during the morning shift. The DON stated it was important to initiate the care plan so facility staff knows the need to supervise, what happen and the type of care and interventions to provide to Patient 1. A review of the facility’s P&P titled, “Abuse Prevention, Screening, & Training Program,” last revised July 2018, the P&P indicated the facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of patient property and/or mistreatment is more likely to occur. A review of the facility’s P&P titled, “Change of condition Notification,” last revised on April 1, 2015, the P&P indicated that the facility would document the change of condition and to update the care plan to reflect the Patient’s status. In violation of the above cited standards, The facility failed to protect Patient 2 from physical abuse against Patient 1, who had a known history of physical aggression toward staff and other patients by failing to: 1. Supervise Patient 1 to prevent Patient 1 from hitting Patient 2 on 8/27/2023, during the 3 PM to 11 PM shift, after Patient 1 had change of condition (COC) manifested by increased verbal/physical aggression and striking out during the 7 AM to 3 PM shift. 2. Ensure that a care plan was initiated when Patient 1 had a change of condition manifested by increased in verbal and physical aggression on 8/27/2023. 3. Follow the facility’s policy and procedure (P&P) titled, “Abuse Prevention, Screening, & Training Program,” that indicated the facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of Patient property and/or mistreatment is more likely to occur. The above violations had a direct or immediate relationship to the health, safety, or security of patients.”