Other·December 12, 2023

CCR § 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. CCR § 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. 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. F600 – Freedom from Abuse, Neglect, and Exploitation FCR §483.12 Freedom from Abuse, Neglect, and Exploitation the Patient has the right to be free from abuse, neglect, misappropriation of Patient 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 Patient’s medical symptoms. FCR §483.12(a) The facility must— FCR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; On 10/30/2023 at 12 p.m., The California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding resident abuse. The facility failed to protect the resident’s right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for Resident 3. On 10/17/2023, at 5:30 p.m., Resident 4 pushed Resident 3 to the floor, got on top of Resident 3 and punched Resident 3. As a result, Resident 3 was subjected to physical abuse by Resident 4 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 3’s severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has physical pain and psychological (mental or emotional) effects including feelings of embarrassment, humiliation, and emotional distress. During a review of Resident 3's Admission Record, the Admission Record indicated, Resident 3 was admitted to facility on 3/9/2022 with multiple diagnoses including Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions), heart failure (condition in which the heart cannot pump enough blood to all parts of the body), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/14/2023, the MDS indicated Resident 3 was severely impaired in cognitive skills (ability to make daily decisions), The MDS indicated Resident 3 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for dressing and personal hygiene. During a review of Resident 4's Admission Record, the Admission Record indicated, Resident 4 was admitted to facility on 10/3/2022 with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a mental illness that causes unusual shifts in a person's mood), and Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 4's MDS, dated 7/13/2023, the MDS indicated Resident 4 was severely impaired in cognitive skills. The MDS indicated Resident 4 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from staff for dressing, transfers, and personal hygiene. During an interview on 10/30/2023 at 3:47 p.m., with Activity Assistant (AA) 2, AA 2 stated on 10/17/2023, around 5:30 p.m., AA 2 was in dining room 3 of the locked unit. AA 2 stated Resident 4 was “already in a mood,” and yelling at other residents. AA 2 stated she asked a Certified Nursing Assistant (CNA) if CAN could take Resident 4. AA 2 stated the CNA refused to take Resident 4 out of the dining room. AA 2 stated Resident 3 then came into the room and sat across from Resident 4. AA 2 stated Resident 4 told Resident 3 to stop talking. AA 2 stated Resident 4 was punching the air which was a behavior Resident 4 would often do. AA 2 stated Resident 3 grabbed a bed side table to use as a barrier between Resident 4. AA 2 stated Resident 4 pushed the bedside table and caused Resident 3 to stumble. AA 2 stated Resident 4 pushed Resident 3 to the ground and sat on top of Resident 3 and began punching Resident 3 on Resident 3’s arms and upper chest while Resident 3 was blocking the blows with his arms. AA 2 stated Resident 4 was saying “yo te mato (Spanish - I’ll kill you)” while Resident 4 was punching Resident 3. AA 2 stated once Resident 4 and another nurse got the residents separated, Resident 4 stated, “do you want to fight me too?” During an interview on 10/31/2023 at 1:38 p.m., with AA 2, AA 2 stated before Resident 4 attacked Resident 3, Resident 4 was arguing with another resident. AA 2 stated Resident 4 was also angry at AA 2. AA 2 stated she wanted Resident 4 to be taken to Resident 4’s room, but CNA (unidentified) refused to take Resident 4. AA 2 stated Resident 4 remained upset the whole time leading up to when Resident 3 entered the room. AA 2 stated Resident 3 sat in Resident 3’s chair for two or three minutes and then grabbed the bedside table to leave the room. AA 2 stated if CNA had removed Resident 3 from the room when AA 2 had asked then the incident would have been avoidable. AA 2 stated Resident 4’s hands were closed while Resident 4 was punching Resident 3. During an interview on 10/31/2023 at 1:53 p.m., with Registered Nurse (RN) 1, RN 1 stated if Resident 4 was agitated during activity time Resident 4 needed to be removed from the room. RN 1 stated agitated residents may be a danger to themselves and to other residents. During an interview on 10/31/2023 at 3:30 p.m., with LVN 3, LVN 3 stated LVN 3 went to the dining room and saw Resident 4 on top of Resident 3. LVN 3 stated LVN 3 helped AA 2 get Resident 4 off Resident 3. LVN 3 stated if a resident is agitated the activity staff need to notify the charge nurse. LVN 3 stated the agitated resident need to be removed from the activity room until the resident (in general) calm down. During a review of Resident 3’s Change in Condition Evaluation (COC), dated 10/17/2023, the COC indicated, “Reported by activity staff the resident was assaulted by another resident.” During a review of Resident 4’s Change in Condition Evaluation (COC), dated 10/17/2023, the COC indicated, “Reported by activity staff the resident assaulted another resident in the dining room.” During a review of Resident 3’s Care Plan, titled “Emotional distress related to: resident was assaulted by another resident,” dated 10/17/2023, the Care Plan indicated Resident 3 was assaulted by another resident. During a review of Resident 4’s Care Plan, titled “Resident assaulted another resident in the dining room,” dated 10/17/2023, the Care Plan indicated Resident 4 assaulted another resident. During a review of the facility’s handwritten statement by AA 2, dated 10/17/2023, the statement indicated AA 2 saw Resident 4 push Resident 3 to the floor. The statement indicated AA 2 saw Resident 4 get on Resident 3 and attack Resident 3. During a review of the facility’s Report of Investigation (Report), dated 10/22/2023, the Report indicated on 10/17/2023, at around 5:35 p.m., Resident 4 pushed a bedside table that Resident 3 was using as support. The Report indicated Resident 3 fell to the floor when Resident 4 pushed the table. During a review of the facility’s P&P titled, “Reporting Abuse,” revised 1/8/2014, the P&P indicated, “The Facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.” The facility failed to protect the resident’s right to be free from physical abuse for Resident 3. On 10/17/2023, at 5:30 p.m., Resident 4 pushed Resident 3 to the floor, got on top of Resident 3, and punched Resident 3. As a result, Resident 3 was subjected to physical abuse by Resident 4 while under the care of the facility. Based on the reasonable person concept due to Resident 3’s severely impaired cognition, an individual subjected to physical abuse has physical pain and psychological effects including feelings of embarrassment, humiliation, and emotional distress. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 3.