Health inspection·November 26, 2024

Freedom from Abuse, Neglect, and Exploitation §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. 22 CFR § 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. 22 CFR § 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. On 10/24/2024, the California Department of Public Health (CDPH) received a complaint alleging the facility had a resident-to-resident altercation, in which Resident 9 was choked by Resident 10. On 10/24/2024, the CDPH conducted an unannounced compliant investigation at the facility. Upon investigation, it was determined there was an incident on 9/17/2024 when Resident 9 was grabbed by the neck and choked by Resident 10. The facility failed to: Implement its Policy and Procedure (P&P) tilted “Abuse Prevention and Management,” dated 6/12/2024, which indicated abuse was the willful, deliberate infliction of injury and physical harm, and physical abuse, was not limited to hitting, slapping punching and/or kicking. As a result, Resident 9 was grabbed by the neck and choked by Resident 10. Findings: a) A review of Resident 9’s Face Sheet indicated the resident was a 73-year-old female, admitted to the facility on 7/5/2024 and readmitted on 7/12/2024. Resident 9’s diagnoses included Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness (loss of muscle strength). A review of Resident 9’s Minimum Data Set ([MDS] – a federally mandated resident assessment tool), dated 7/19/2024, the MDS indicated Resident 9’s cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired. The MDS indicated Resident 9 required maximal assistance (helper does more than half the effort) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 9’s situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/17/2024 at 5:07 p.m., indicated Resident 9 was grabbed by the head by Resident 10. b) A review of Resident 10’s Face Sheet indicated the resident was a 66-year-old male, admitted to the facility on 6/24/2024 and readmitted on 10/1/2024. Resident 10’s diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), hypertension (HTN-high blood pressure), and muscled weakness. A review of Resident 10’s MDS, dated 10/15/2024, the MDS indicated Resident 10’s cognitive skills for daily decisions making was intact. A review of Resident 10’s SBAR, dated 9/17/2024 at 5:00 p.m., indicated Resident 10 was in Resident 9’s room and grabbed Resident 9’s head to choke her. The SBAR indicated Resident 10 stated “I heard voices telling me to do it, and I couldn’t stop it.” A review of Resident 10’s progress note, dated 9/17/2024 at 10:40 p.m., indicated Resident 10 was transferred to the GACH for psychiatric evaluation (a clinical assessment of a person’s mental health status) for hearing voices. A review of Resident 10’s general acute care hospital (GACH) admission record, dated 9/18/2024, the GACH admission record indicated Resident 10 was admitted to the GACH on 9/18/2024 for a psychiatric evaluation. The GACH admission record indicated Resident 10 tried to choke Resident 9 at the facility. During a telephone interview on 10/29/2024 at 4:11 p.m., with Licensed Vocational Nurse (LVN 5), LVN 5 stated in the evening of 9/17/2024, he (LVN 5) was at the nurses’ station and heard yelling and screaming for help coming from Resident 9’s room. LVN 5 stated he walked into Resident 9’s room and observed Resident 10 standing over Resident 9, grabbing her by the neck with his hands and choking Resident 9. c)A review of Resident 11’s Face Sheet, the Face Sheet indicated the resident was 62-year-old female, admitted to the facility on 4/11/2024. Resident 11’s diagnoses included chronic obstructive pulmonary disease ([COPD]-a chronic lung disease causing difficulty in breathing) and Diabetes Mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 11’s MDS, dated 9/18/2024, the MDS indicated Resident 11’s cognitive skills for daily decisions making was intact. During an interview on 10/30/2024 at 8:25 a.m., with Resident 11, Resident 11 stated on 9/17/2024, she observed Resident 10 in their room (Resident 9, and 11). Resident 11 stated, Resident 10 grabbed Resident 9’s neck and choked her. During an interview on 10/30/2024 at 9:00 a.m., with the Director of Nursing (DON), the DON stated Resident 10’s action toward Resident 9 was resident to resident physical abuse. A review of the facility’s Policy and Procedure (P&P) titled “Abuse-Reporting & Investigations”, revised 3/2018, the P&P indicated facility would protect the health, safety, and welfare of facility residents. A review of the facility’s P&P tilted “Abuse Prevention and Management”, dated 6/12/2024, indicated abuse was the willful, deliberate infliction of injury and physical harm. The P & P indicated physical abuse, was not limited to hitting, slapping punching and/or kicking. The facility failed to: Implement its Policy and Procedure (P&P) tilted “Abuse Prevention and Management”, dated 6/12/2024, indicated abuse was the willful, deliberate infliction of injury and physical harm, and physical abuse, was not limited to hitting, slapping punching and/or kicking. As a result, Resident 9 was grabbed by the neck and choked by Resident 10. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.