Health inspection·March 6, 2024

Code of Federal Regulations, Title 42, Section §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. California Code of Regulations, Title 22, Section § 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. § 72527. Patient 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. On 2/6/24 at 9:30 am. the California Department of Public Health (CDPH, the Department) conducted an unannounced abbreviated standard survey visit to the facility. As a result of the investigation, the Department determined the facility failed to ensure Resident 1 and Resident 6 were free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by failing to: 1. Protect Resident 1 and Resident 6 from physical abuse when Resident 2 physically assaulted (the illegal act of causing physical harm or unwanted physical contact to another person) Resident 1 and Resident 6 on 2/3/2024 at 6:45 a.m. 2. Ensure Licensed Vocational Nurse (LVN) 2 notified the Director of Nursing (DON) of Resident 2's aggressive behavior on 2/2/2024 in accordance with the facility's policy and procedure (P&P) titled, "Resident-To-Resident Altercations." As a result, on 2/3/2024 at 6:45 a.m., Resident 2 hit Resident 1 and 6 while under the care of the facility. Resident 1 sustained swelling (enlargement of a body part) and contusion (bruising or skin discoloration) on Resident 1's right eye, face, left cheek with slight (small amount) bleeding from Resident 1's mouth, and hematoma (a collection of blood outside of blood vessels) on Resident 1's left scalp (the skin covering the head). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 2/3/2024 at 7:34 a.m. for further evaluation and care. Resident 6 sustained an abrasion (a superficial rub or wearing off from the skin) on Resident 6's right eye and discoloration on the left side of Resident 6's face. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1's and Resident 6's severely impaired cognition (ability to think and process information), an individual subjected to physical abuse would have suffered physical pain and psychological (mental or emotional) effects including feelings of fear, embarrassment, humiliation, and emotional distress. 1. A review of Resident 1's "Admission Record (AR), indicated the facility admitted Resident 1, an 82-year-old male to the facility on 2/24/2023 with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 1's "History and Physical Examination (H&P)," dated 2/27/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's "Minimum Data Set (MDS, a standardized assessment and care screening tool)," dated 12/1/2023, indicated Resident 1 had severely impaired cognitive skills. The "MDS" indicated, Resident 1 required supervision or touch assistance (helper provided verbal cues and/or touching/steadying and/or guard assistance) from staff for eating, dressing, and personal hygiene. A review of Resident 1's "eINTERACT Change in Condition Evaluation (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains)," dated 2/3/2024, timed at 7:06 a.m., the COC indicated (on 2/3/2024) at 6:45 a.m., LVN 1 found Resident 1 on the floor (in Resident 1's room) with "slight blood" on Resident 1's mouth and a swollen right eye. The "COC" indicated, Resident 1 had a physical altercation (a dispute between individuals in which one or more persons sustain bodily injury) with Resident 2, who was Resident 1's roommate. The "COC" indicated, Registered Nurse (RN) 1 assessed Resident 1 and immediately called 911 to send Resident 1 to the GACH 1 per Resident 1's Physician's (Physician 1's) order. A review of Resident 1's "Progress Notes," dated 2/3/2024, timed at 8:19 a.m., indicated on 2/3/2024 at 6:45 a.m., Resident 2 hit Resident 1 on Resident 1's face. The "Progress Notes" indicated, the facility called 911 and Resident 1 was transferred to GACH 1. A review of Resident 1's GACH 1 "Emergency Department Note Physician (ED Note)," dated 2/3/2024, timed at 12:41 p.m., indicated Resident 1 presented to GACH 1's emergency room on 2/3/2024 at 7:34 a.m. with complaint of (c/o) face pain and facial trauma status post (s/p, condition after) assault by roommate (Resident 2). The "ED Note" indicated, Resident 1 had bruising over Resident 1's right eyelid and face and bleeding from Resident 1's mouth. The "ED Note" indicated, Resident 1 would be admitted to GACH 1 for further evaluation. A review of Resident 1's GACH 1 "Computed Tomography (CT scan, a diagnostic imaging exam)," of the head report, dated 2/3/2024, timed at 9:20 a.m., indicated Resident 1 had swelling and contusion on Resident 1's left cheek and hematoma on Resident 1's left scalp. A review of Resident 1's GACH 1 Infectious Disease Physician "Consultation Notes," dated 2/4/2024, timed at 8:02 p.m., indicated Resident 1's face was still swollen and had periorbital edema (swelling around the eyes). 2. A review of Resident 6's "AR," indicated the facility admitted Resident 6, an 81-year-old male, to the facility on 12/5/2023 with diagnoses that included dementia, anxiety disorder (a mental health condition characterized by persistent and excessive worry that interferes with one's daily activities), and lack of coordination (not able to move different parts of the body together well or easily). A review of Resident 6's "MDS," dated 12/12/2023, indicated Resident 6 had severely impaired cognitive skills. The "MDS" indicated, Resident 6 required supervision or touch assistance from staff for toileting hygiene, dressing, and personal hygiene. A review of Resident 6's "COC," dated 2/3/2024, timed at 8:46 a.m., indicated (on 2/3/2024) at 6:45 a.m., LVN 1 heard Resident 6 yelling for help from Resident 6's room. The "COC" indicated, LVN 1 entered Resident 6's room and found Resident 6 yelling that Resident 2 (Resident 6 and Resident 1's roommate) hurt Resident 6. The "COC" indicated, Resident 6 was immediately assisted out of Resident 6's room and gently separated from Resident 2. The "COC" indicated, Resident 6 had an abrasion on Resident 6's right eye and discoloration on the left side of Resident 6's face. 3. A review of Resident 2's AR, indicated the facility admitted Resident 2, a 58-year-old male to the facility on 1/23/2024 with diagnoses that included paranoid (where a person feels distrustful and suspicious of other people) schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and anxiety disorder. A review of Resident 2's "H&P," dated 1/24/2024, indicated Resident 2 can make needs known but cannot make medical decisions. A review of Resident 2's "MDS," dated 1/30/2024, indicated Resident 2 had severely impaired cognitive skills. The "MDS" indicated, Resident 2 required partial/moderate assistance from staff for toileting hygiene, dressing, and personal hygiene. A review of Resident 2's "COC," dated 2/3/2024, timed at 8:08 a.m., indicated on 2/3/2024 at 6:30 a.m., Resident 2 came out of Resident 2's room and requested to smoke a cigarette. The "COC" indicated, LVN 1 informed Resident 2 that it was not time for a smoke-break. The "COC" indicated, Resident 2 started displaying behaviors towards LVN 1 by swinging Resident 2's arms towards LVN 1 and touching LVN 1. The "COC" indicated, LVN 1 redirected Resident 2 back to Resident 2's room and offered Resident 2 snacks and juice. The "COC" indicated, after Resident 2 ate the snacks, LVN 1 informed Resident 2 that he could smoke after breakfast. The "COC" indicated, Resident 2 stayed calm in Resident 2's room. The "COC" indicated, (on 2/3/2024) at 6:45 a.m., LVN 1 and other staff heard Resident 6 (Resident 1 and Resident 2's roommate) calling for help and LVN 1 and other staff immediately ran into Resident 6, Resident 1, and Resident 2's room. The "COC" indicated, LVN 1 found Resident 2 with blood on his hands and Resident 1 on the floor with slight blood on Resident 1's face. The "COC" indicated no documentation regarding Resident 6's condition. A review of Resident 2's "Progress Notes," dated 2/3/2024, timed at 2:47 p.m., indicated the facility transferred Resident 2 to GACH 2 at 12:40 p.m. (on 2/3/2024) due to an increase in aggressive behavior. The "Progress Notes" indicated, Resident 2's right hand was swollen. During a telephone interview on 2/6/2024 at 10:25 a.m., LVN 1 stated on 2/3/2024, at "around" 6:30 a.m., Resident 2 asked LVN 1 for a cigarette. LVN 1 stated LVN 1 told Resident 2 that smoking time was after breakfast then Resident 2 became upset. LVN 1 stated Resident 2 started swinging at LVN 1 and "tapped" LVN 1's shoulder. LVN 1 stated LVN 1 gave Resident 2 a "snack" then Resident 2 calmed down. LVN 1 stated after Resident 2 ate the snack, Resident 2 went back to Resident 2's room and laid down in Resident 2's bed. LVN 1 stated about 5 minutes later, LVN 1 heard Resident 6 screaming from Resident 6, Resident 2, and Resident 1's room (roommates). LVN 1 stated when LVN 1 entered Resident 6's room, LVN 1 saw Resident 6 trying to get out of Resident 6's bed. LVN 1 stated LVN 1 saw Resident 1 on the floor with swelling on Resident 1's (right) eye and blood near Resident 1's mouth. LVN 1 stated LVN 1 saw Resident 2 standing by Resident 1's bedside with blood on Resident 2's hands. LVN 1 stated the facility called 911 because of Resident 1's injury. LVN 1 stated Resident 6 claimed Resident 2 tried to hurt Resident 1 and Resident 6. LVN 1 stated Resident 6 had abrasion on Resident 6's right eye and discoloration on the left side of Resident 6's face. During a concurrent observation and interview on 2/6/2024 at 11:21 a.m. with Resident 6, in Resident 6's room, Resident 6 had a purple line under Resident 6's left eye and a purple spot on the bridge of Resident 6's nose. Resident 6 pointed to Resident 2's bed and stated Resident 2 started to act up and started to touch Resident 6. Resident 6 stated Resident 2 was fighting everybody. Resident 6 stated Resident 2 "pounded on this guy" and pointed to Resident 1's bed. During a concurrent observation and interview on 2/6/2024 at 3:15 p.m. with GACH 1's RN 2, in Resident 1's room at GACH 1, Resident 1 was lying in Resident 1's bed with Resident 1's eyes shut. Resident 1's lips and bilateral (affecting both sides) eyelids were swollen. The left side of Resident 1's face was dark purple. GACH 1's RN 2 stated Resident 1's eyelids were swollen shut. GACH 1 RN 1 stated Resident 1 had an admission diagnosis of "s/p assault." During a concurrent interview and record review on 2/7/2024 at 7:33 a.m. with LVN 2, Resident 2's Care Plan titled, "The Resident Is Refusing Medications and Being Physically Aggressive with Staff," initiated on 2/2/2024, was reviewed. LVN 2 stated LVN 2 created the Care Plan because Resident 2 got aggressive with staff on 2/2/2024. LVN 2 stated Resident 2's demeanor (outward behavior) was aggressive, and that Resident 2 would "get up in our (staff) face like he (Resident 2) was trying to intimidate us (staff)." LVN 2 stated LVN 2 did not notify the Director of Nursing (DON) when Resident 2 was aggressive with staff (on 2/2/2024). LVN 2 stated LVN 2 should have notified the DON of Resident 2's aggression so the DON could have considered providing one-to-one (1:1, one staff supervised one resident) supervision (provide continuous observation for an individual patient for a period of time during acute physical or mental illness) for Resident 2. During an interview on 2/7/2024, at 8:20 a.m. with the DON, the DON stated LVN 2 did not notify the DON of Resident 2's aggressive behavior on 2/2/2024. The DON stated LVN 2 needed to notify the DON about Resident 2's aggression so the DON could transfer Resident 2 for an evaluation or placed Resident 2 on 1:1 supervision. The DON stated residents who have any kind of aggressive behaviors could escalate to becoming physically aggressive. During a concurrent interview and record review on 2/7/2024, at 8:27 a.m. with the Director of Staff Development (DSD) 1, the P&P titled, "Resident-To-Resident Altercations," revised on 11/1/2015, was reviewed. The P&P indicated, the facility acted promptly and conscientiously to prevent and address altercations between residents. The P&P indicated, facility's staff observed residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or facility staff. The P&P indicated, any occurrences of such behavior are promptly reported to the Charge Nurse, the Director of Nursing Services, and the Administrator. DSD 1 stated staff must report aggressive behaviors of residents to the DON per the facility's P&P. DSD 1 stated the DON needed to be notified, even if there was no physical altercation with the aggressive behavior. A review of the facility's P&P titled, "Reporting Abuse," revised on 1/8/2014 indicated, the facility will ensure that the residents have the right to be free from verbal, sexual, physical, and mental abuse. As a result of the investigation, the Department determined the facility failed to ensure Resident 1 and Resident 6 were free from physical abuse by failing to: 1. Protect Resident 1 and Resident 6 from physical abuse when Resident 2 physically assaulted Resident 1 and Resident 6 on 2/3/2024 at 6:45 a.m. 2. Ensure LVN 2 notified the DON of Resident 2's aggressive behavior on 2/2/2024 in accordance with the facility's P&P titled, "Resident-To-Resident Altercations." As a result, on 2/3/2024 at 6:45 a.m., Resident 2 hit Resident 1 and 6 while under the care of the facility. Resident 1 sustained swelling and contusion on Resident 1's right eye, face, left cheek with slight bleeding from Resident 1's mouth, and hematoma on Resident 1's left scalp. Resident 1 was transferred and admitted to GACH 1 on 2/3/2024 at 7:34 a.m. for further evaluation and care. Resident 6 sustained an abrasion on Resident 6's right eye and discoloration on the left side of Resident 6's face. Based on the reasonable person concept due to Resident 1's and Resident 6's severely impaired cognition, an individual subjected to physical abuse would have suffered physical pain and psychological effects including feelings of fear, embarrassment, humiliation, and emotional distress. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 1 and 6.