Health inspection·July 17, 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. 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. § 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 6/4/2024 at 12 p.m., the California Department of Public Health (CDPH, the Department) conducted an unannounced abbreviated standard survey visit to investigate a facility reported incident regarding an allegation of resident abuse. As a result of the investigation, the Department determined the facility failed to ensure Resident 4 was free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) by failing to protect Resident 4 from physical abuse and remove Resident 4 immediately when Resident 5 physically assaulted (the illegal act of causing physical harm or unwanted physical contact to another person, physical attack) Resident 4. As a result, Resident 4 felt unsafe, scared, experienced pain, an abrasion (a cut or a scrape on the skin) that required treatment and Resident 4 was transferred to General Acute Care Hospital (GACH) 1's Emergency Department (ED) for further evaluation. a. A review of Resident 5's "Admission Record," indicated the facility admitted Resident 5, a 75-year-old male, to the facility on 7/24/19 and readmitted on 5/7/24 with multiple diagnoses including schizophrenia, Alzheimer's and unspecified psychosis not due to a substance or known physiological condition. A review of Resident 5's ""History and Physical Examination (H&P)," dated 11/4/23, indicated Resident 5 did not have the capacity to understand and make own decisions. A review of Resident 5's "Minimum Data Set (MDS, an assessment and screening tool)," dated 3/1/24, indicated, Resident 5's cognitive status was severely impaired. The MDS indicated, Resident 5 was taking antipsychotic medications (main class of drugs used to treat people that have mental disorders). A review of Resident 5's Care Plan (CP), titled, "Resident has allege[d] abuse with another resident," initiated on 4/18/24, indicated for Resident 5 receive "one to one (1 staff supervise Resident 5) and move to other unit/room." A review of Resident 5's GACH 2's "Progress Note - Physician (PNP)," dated 5/5/24, timed at 9:01p.m., indicated Resident 5 had poor impulse control and [was a] danger with an intention to hurt others. A review of Resident 5's “Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains)," report dated 6/2/24, timed at 1:37 p.m., indicated in the morning of 6/2/24, Resident 5 had behavioral symptoms (e.g., agitation, psychosis) and had physical interaction with [another] resident. A review of Resident 5's "Progress Notes (PN)," dated 6/2/2024, timed at 1:37 p.m., indicated during the activities in the dining room located in Station 2 (Vicinity), Resident 5 had an altercation with another resident (Resident 9). The "PN" indicated, the facility obtained a physician's order for a 51:50 hold (an emergency involuntary psychiatric [refers to a broad range of problems that disturb a person's thoughts, feeling, behavior or mood] 72-hour hold of individuals who pose a danger to themselves or others) on Resident 5. A review of Resident 5's Physician Phone Order (PPO)," dated 6/2/24 timed at 2:10 p.m., indicated to transfer Resident 5 to GACH 2 on a 5150 hold. b. A review of Resident 4's "AR," indicated the facility admitted Resident 4, a 47-year-old male to the facility on 3/11/22 with multiple diagnoses including nontraumatic intracerebral hemorrhage, unspecified, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side and generalized anxiety disorder. A review of Resident 4's "H&P," dated 12/8/23, indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4's "MDS," dated 3/4/24, indicated Resident 4's cognition status was moderately impaired. The MDS indicated, Resident 4 was taking antianxiety medications. A review of Resident 4's "eINTERACT Change in Condition Evaluation COC," dated 6/2/24, timed at 11:15 a.m., indicated in the morning of 6/2/24, there was a resident-to-resident altercation (a negative, often aggressive, interactions between residents in long-term care communities). The "COC" indicated there was a scratch on Resident 4's left side of the forehead after the altercation. A review of Resident 4's "Progress Notes (PN)," dated 6/2/2024, timed at 11:15 a.m., indicated during the activities in the Vicinity, Resident 5 suddenly stood up from Resident 5's chair, walked towards Resident 4 and hit Resident 4 on Resident 4's left forehead. Activity staff (unidentified) immediately called for help and tried to intervene between Resident 5 and Resident 4. When staff separated Resident 5 and Resident 4, Resident 5 got a chair and threw it at Resident 4 but missed. Staff (unidentified) continued to redirect Resident 5 to escort out of the Vicinity but Resident 5 was able to pick up another chair, threw it at Resident 4, and hit Resident 4's neck. A review of Resident 4's GACH 1 "ED Note Physician (EDNP)," dated 6/2/24, timed at 2:29 p.m., indicated Resident 4 presented to GACH 1's ED on 6/2/24 at 4:21 p.m. with chief complaint of facial pain (unrated) and assault by someone (unnamed), at the facility. The EDNP indicated someone threw a chair and hit Resident 4 in the throat area. The "EDNP" indicated Resident 4 had an abrasion on the left side of Resident 4's forehead that started from Resident 4's cheek and went circularly around Resident 4's orbit (the eye-socket, cavity in the skull that holds the eye) to Resident 4's forehead. The "EDNP" indicated, Resident 4 had diagnoses that included head injury, abrasion, and chest wall pain. A review of Resident 4's "PN," dated 6/2/2024, timed at 7:15 p.m., indicated Resident 4 returned from GACH 1 to the facility via a gurney accompanied by two Emergency Medical Technicians. The "PN" indicated Resident 4 had a skin scratch on the left side of the forehead "as the result from the altercation." A review of Resident 4's "Order Summary Report (OSR)," active orders as of 6/6/24, indicated an order, dated 6/2/24 to send Resident 4 to ER by calling 911 for further evaluation of the hit on [Resident 4's] head. The "OSR" indicated, an order on 6/2/24 to cleanse the left lateral (relating to the side) forehead with NS (normal saline solution, mixture of water and salt and used to cleanse wounds) pat to dry, apply triple antibiotic ointment, and leave air to dry every shift for scratch for seven (7) days. During a concurrent observation and interview on 6/4/24 at 12:54 p.m., with Resident 4, Resident 4 was sitting up in a wheelchair and wheeled himself around by using Resident 4's right hand. Resident 4 had left sided weakness and was unable to move Resident 4's left arm. Resident 4 was observed to have a dry, long reddish colored scratch mark above Resident 4's left eyebrow extending to Resident 4's left temple area. Resident 4 stated, Resident 4 went into the Vicinity on 6/2/24 at around 11:30 a.m. and Resident 5 who was sitting at a table away from Resident 4 jumped at and started hitting Resident 4 while saying "MF" (explicit word). Resident 4 stated, Resident 4 got mad and said, "FU (explicit word) " to Resident 5. Resident 4 stated, Resident 5 flipped out, grabbed a heavy chair, threw it at Resident 4, and the chair hit Resident 4's chest. Resident 4 stated, Resident 5 was, "still going crazy," picked up another chair, and threw the chair at Resident 4. Resident 4 stated, the chair hit Certified Nursing Assistant (CNA) 2. Resident 4 stated, no staff tried to remove Resident 5 from the Vicinity, "everyone was scared of the guy [Resident 5]" and Resident 4 felt staff were not going to do something [about the incident]. Resident 4 stated, Resident 4 was sent to GACH 1 to get checked. Resident 4 stated Resident 4 had pain in his head. Resident 4 stated, Resident 4 did not want to see Resident 5 and feared that Resident 5 might attack Resident 4 again if Resident 5 saw Resident 4. Resident 4 stated, "I can't stand up and defend myself" and "honestly, I'm scared." Resident 4 stated, Resident 5 had hit other residents in the past [at the facility]. During an interview on 6/6/24 at 9:20 a.m. with the Activities Aide (AA), the AA stated, on 6/2/24 after 11 a.m., in the Vicinity, Resident 5 suddenly hit "punched" Resident 4 who was sitting in a wheelchair on Resident 4's left temple of Resident 4's face. The AA stated, the AA tried to talk and approach Resident 5 but Resident 5 ran and grabbed a heavy wood chair and Resident 5 threw the wood chair at Resident 4. The AA stated, Resident 5 ran and grabbed another chair (metal chair) and threw it at Resident 4 again, the metal chair hit Resident 4. The AA stated, staff did not remove Resident 5 out of the Vicinity because Resident 5 was big, very strong, and mad. The AA stated this was not the first time Resident 5 "attacked another resident." The AA stated, it was important to separate or remove either the aggressor or the victim out of the Vicinity "to not make the situation worse." During an interview on 6/6/24 at 9:57 a.m. with CNA 3, CNA 3 stated, on 6/2/24 before 12 p.m., CNA 2 and CNA 3 were in the nursing station and heard a commotion from the Vicinity, a resident (unnamed) screamed "stop it! stop it!" CNA 2 and CNA 3 ran into the Vicinity and saw Resident 5 walking away from Resident 4 and went back to Resident 5's chair. CNA 3 asked Resident 4 if Resident 4 was okay and CNA 3 saw Resident 4 bleeding from Resident 4's left side of the forehead next to Resident 4's temple. CNA 3 stated, CNA 3 removed Resident 4's hat and saw Resident 4 "was bleeding a lot" and Resident 4 had a "very scared" expression on his face. CNA 3 stated, Resident 5 got up from his chair, grabbed a chair, threw the chair at Resident 4, and at CNA 2 but the chair landed on the floor. CNA 3 stated, Resident 5 went to grab another chair and threw it at Resident 4 and the chair's leg hit Resident 4's chest area. CNA 3 stated, Resident 5 walked across the Vicinity and attempted to grab another chair but by that time more staff had arrived. CNA 3 stated, Licensed Vocational Nurse (LVN) 2 calmed Resident 5 down and Resident 5 remained in his chair in the Vicinity while staff removed Resident 4 out of the Vicinity. CNA 3 stated, staff did not attempt to remove Resident 5 [out of the Vicinity] during the incident because Resident 5 was very aggressive, and the staff were afraid "I think for fear." CNA 3 stated, CNA 3 did not know why Resident 4 was not removed out of the Vicinity right away. CNA 3 stated, it was important to remove either Resident 4 or Resident 5 out of the Vicinity "to cut the tension, cut the contact, to prevent for another incident" and Resident 4 from "getting hit and getting injured." During an interview on 6/6/24 at 12:53 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, the ADON was aware Resident 5 has had another altercation with another resident (unidentified) "not too long ago." The ADON stated, Resident 5 was not removed from the Vicinity because "there is a fine line between keeping the residents and our staff safe." The ADON stated, staff could have removed Resident 4 out of the Vicinity instead, "that's another way of deescalating," "that's another option that was available," but staff was more focused on Resident 5. The ADON stated, it was reasonable to state that facility could have removed Resident 4 from the Vicinity and [could have] prevented the situation from escalating. A review of the facility's policy and procedure (P&P) titled, "Reporting Abuse," date revised 1/8/2014, indicated, the facility will ensure that the residents have the right to be free from verbal, sexual, physical, and mental abuse. A review of the facility's P&P titled, "Abuse - Reporting & Investigations," date revised 3/2018, indicated to protect the health, safety, and welfare of facility residents, an immediate action was for the administrator or designated representative to provide for a safe environment for the resident as indicated by the situation. A review of the facility's P&P titled, "Abuse - Prevention, Screening, & Training Program," date revised 7/2018, indicated the facility identifies, corrects, and intervenes in situations in which abuse ... is more likely to occur. A review of the facility's, "Inservice Meeting Minutes (IMM)," titled "Abuse Prevention and Reporting," dated 5/16/24 and 6/3/24, titled, "Abuse," dated 5/23/24, titled, "Elder Abuse & Prevention," dated 5/25/24, titled, "Abuse, resident to resident altercation," dated 5/29/24, indicated, the course content included understanding stress and abusive behaviors and it was the important for staff to be trained to effectively recognize and deal with residents who exhibit aggressive or noncompliant behavior. A review of the facility's "Resident to Resident (RR)," list, dated from 1/2024 to 6/4/2024, indicated, Resident 5 had three resident-to-resident altercations on the following dates: 1/23/24; 4/18/24 and 6/2/24. As a result of the investigation, the Department determined the facility failed to ensure Resident 4 was free from physical abuse by failing to protect Resident 4 from physical abuse and remove Resident 4 immediately when Resident 5 physically assaulted Resident 4. As a result, Resident 4 felt unsafe, scared, experienced pain, an abrasion that required treatment, and was transferred to GACH 1's ED to further evaluation. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 4.