Health inspection·October 30, 2024

§ 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. § 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. § 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 §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; An unannounced visit was conducted by California Department of Public Health on 9/17/2024 at 1:20 PM to investigate a facility reported incident regarding sexual (sexual behavior or a sexual act [with the intent to arouse or gratify sexual desire a person touches the anus, breast, or the genitals of another] forced upon a woman, man, or child without their consent). The facility failed to prevent sexual abuse to Patient 1 by failing to have measures in place to prevent Patient 2 from repeating sexual inappropriate behaviors. On 9/14/2024, Patient 2 touched and squeezed Patient 1’s left breast while in the activity room and was witnessed by Activity Aide (AA). This failure placed Patient 1 at risk for emotional or mental trauma and other residents in the facility at risk for sexual abuse. A review of Patient 1's Admission Record indicated the patient is a 68- year- old- female patient who was initially admitted to the facility on 1/18/2001 and readmitted on 8/14/2024 with diagnoses of hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following cerebral infarction (a damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) in chronic kidney disease (condition that occurs when the kidneys are damaged and can't filter blood properly), and type 2 diabetes mellitus (high blood sugar levels in blood stream) without complications. A review of Patient 1's History and Physical Examination (H&P) dated 9/7/2024 indicated Patient 1 had no capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 7/17/2024, indicated Patient 1 had severe cognitive impairment status (mental action or process of acquiring knowledge and understanding). The MDS also indicated Patient 1 was dependent (helper does all the effort) on lower body dressing, shower, bath, and personal hygiene. The MDS indicated Patient 1 required substantial /maximal assistance (helper does more than half of the effort) on oral hygiene, toileting hygiene, and upper body dressing. A review of Patient 1’s “Progress Notes” dated 9/14/2024 at 3 PM, indicated, Patient 1’s breast was touched by another patient (Patient 2) in the activity room, that was witnessed by the AA on 9/14/24 at 10:10 AM. A review of Patient 2’s Admission Record indicated Patient 2 was admitted to the facility on 5/3/2019 and readmitted on 6/1/2023 with diagnoses that included hypertensive heart disease (a group of conditions that can occur when chronic high blood pressure damages the heart) with heart failure (the heart is unable to pump enough blood to meet the body's needs), type 2 diabetes mellitus (high blood sugar level in the blood stream), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Patient 2’s H&P, dated 3/22/2024, H&P indicated the patient has the capacity to understand his medical condition or his bill of rights (a patient’s rights and responsibilities). A review of Patient 2's MDS dated 8/2/2024, the MDS indicated Patient 2 was able to follow commands, his cognition skills was moderate impaired for decision making. Patient 2 required helper to do less than half of the effort for patient for the toilet, personal hygiene. The MDS also indicated Patient 2 required less than half of the effort for change of position and transfer. Patient 2 is moderate dependent. During a telephone interview on 9/17/2024 at 3:53 PM with the AA, AA stated. on 9/14/2024 morning around 10:10 AM while in the activity room, she saw Patient 2 standing behind Patient 1 and Patient 2’s left hand was touching and squeezing Patient 1’s left breast (AA demonstrated how Patient 2’s left hand was touching and squeezing Patient 1’s left breast, through telephone video interview). During an interview with Patient 1 on 9/17/2024 at 2:07 PM, Patient 1 shook her head, her face looks sad, and Patient 1 did not answer question when asked about Patient 2’s inappropriate touching and squeezing of her breast in the activity room on 9/14/2024 around 10:10 AM. During a concurrent interview and record review on 9/18/2024 at 9:02 AM with Assistant Director of Nursing 2 (ADON2), Patient 2’s nursing progress note dated 3/3/2024 and 9/14/2024 were reviewed. ADON2 stated the 9/14/2024 episode was not Patient 2’s first episode of sexual abuse to other patient in the facility. ADON2 confirmed there was a former sexual abuse of Patient 2 to another female patient on 3/3/2024. ADON2 stated Patient 2 needed to be monitored besides psychiatric evaluation. ADON2 stated it was not enough and was unsafe to transfer Patient 2 from one unit to another unit, because this will expose risk to other female patients in the new unit Patient 2 was placed. During an interview on 9/18/2024 at 9:14 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated there were no documented evidence of monitoring and care plans in place to address and prevent Patient 2 from repeating his sexual inappropriate behaviors from 9/17/2024 to 9/18/2024. During an interview on 9/18/2024 at 10:46 AM with SSW, SSW stated Patient 2 must be monitored, he was allowed to get out of his unit and go to the smoking area by himself without any form of facility staff monitoring the patient at this time. SSW stated transferring of Patient 2 from one unit to another will expose other female patients in the new unit for potential or risk of sexual abuse by Patient 2. During an interview on 9/18/2024 at 12:48 PM with Certified Nursing Assistant (CNA 2), CNA 2 confirmed that there is no specific process or plan to prevent Patient 2 from repeating his sexual inappropriate behavior today (9/18/2024). During an observation on 9/18/2024 at 12:58 PM in the smoking area and hallway near smoking area, observed Patient 2 was sitting in the wheelchair and Patient 2 was wheeling himself without anyone monitoring him. During an interview on 9/18/2024 at 1:26 PM with the Director of Nursing (DON), the DON confirmed, there was no monitoring and interventions in place to prevent Patient 2 from repeating his sexual inappropriate behavior. The DON also stated it is a potential for another sexual abuse to other patients if Patient 2 kept being transferred from unit to unit without appropriate monitoring and interventions in place to prevent the patient from repeating his sexual inappropriate behavior. During a review of facility Policy and Procedure (P&P) titled “Abuse Prevention and Prohibition Program” revised date 8/1/2023, indicated, purpose was to ensure the facility established operationalized and maintain an abuse prevention and prohibition program designed to screen and train employees, and protect patients. Each resident has the right to be free from abuse (improper usage or treatment of a person or thing), neglect (failure to provide necessary care, assistance, or supervision to a resident), mistreatment (inappropriate treatment or exploitation of a resident) and or misappropriation of property (illegal use of another person's property or funds for personal gain or other unauthorized purpose). The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff and other residents. The facility failed to prevent sexual abuse to Patient 1 by failing to have measures in place to prevent Patient 2 from repeating sexual inappropriate behaviors. On 9/14/2024, Patient 2 touched and squeezed Patient 1’s left breast while in the activity room and was witnessed by Activity Aide (AA). This failure placed Patient 1 at risk for emotional or mental trauma and other residents in the facility at risk for sexual abuse. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.