Health inspection·February 23, 2023

42 CFR §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 22 CCR §72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. 22 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. The facility failed to protect the resident’s right to be free from physical abuse when Certified Nursing Assistant 1 (CNA) grabbed the back collar of Resident 1’s gown (who was severely cognitively impaired [never or rarely made decisions]) and pushed Resident 1 into the resident’s room. As a result, on 11/24/2022, Resident 1 was evaluated for injury and distress, and was at risk for negative psychological impact due to the alleged physical abuse. A reasonable person would have suffered emotional distress such as becoming fearful and suffer psychosocial harm when remembering the incident. On 12/8/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a concern regarding employee to resident physical abuse. A review of the admission record indicated Resident 1 was readmitted to the facility on 7/5/2022, with diagnoses including Alzheimer’s Disease (a progressive disease that destroys memory and other important mental functions), diabetes mellitus Type II (a chronic condition that affects the way the body processes blood sugar), and hypertension (HTN - elevated blood pressure). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 9/26/2022, indicated Resident 1 was severely cognitively impaired and required limited assistance with one person assist for bed mobility, transfer, and walk in corridor. The MDS indicated Resident 1 was not steady, only able to stabilize with staff assistance with no upper and lower extremity impairments. According to a review of the facility’s Elder Abuse in-service records, CNA 1 received Elder Abuse training on 11/17/2022. A review of Resident 1’s nursing progress note, dated 11/24/2022 at 11:11 AM indicated the police were contacted for a report alleging physical abuse of CNA 1 and Resident 1. A review of Resident 1’s Change of Condition form (COC - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 11/24/2022 indicated Resident 1 had an alleged physical abuse. The primary physician recommended to monitor for any negative psychological impact status post alleged physical abuse. The COC did not indicate the perpetrator of the alleged abuse or any description of the alleged abuse. A review of the staff assignment sheet, dated 11/24/2022, indicated Certified Nursing Assistant 1 (CNA 1) was assigned to Resident 1. According to a review of Resident 1’s care plan for physical abuse, initiated on 11/24/2022, the care plan interventions included to evaluate for injury or distress and take actions. The care plan indicated Resident 1 was at risk for negative psychological impact due to alleged physical abuse, on 11/24/2022. A review of Resident 1’s interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) note, dated 11/25/2022 for physical abuse indicated to observe resident for any psychological impact and emotional distress. Resident 1 had Alzheimer’s disease and had no recollection of what happened. During an interview on 12/8/2022 at 10:45 AM, the Receptionist (RCT) stated that on 11/24/2022 8:30 AM he was at the reception desk in the front of the office. He stated he observed Resident 1 walking in the hallway with Resident 2. The RCT stated he observed CNA 1 approach Resident 1, and CNA 1 grabbed Resident 1 by the collar on the back of gown with right hand and pushed Resident 1 into the room. The RCT stated he did not see what occurred after CNA 1 and Resident 1 entered the room. The RCT stated the Housekeeper (HK) approached him and told the RCT he witnessed CNA 1 push Resident 1 to her bed. According to a review of CNA 1’s Notice of Employee as to Change in Relationship, dated 12/9/2022, indicated discharge effective date 12/9/2022. A review of the Psychiatric Note dated 12/12/2022, indicated Resident 1 was interviewed due to the alleged abuse done by CNA 1. Resident 1 was unable to recall the incident. The Psychiatric Note indicated to provide emotional support for compliance with treatment, increase socialization to prevent isolation, and continue to monitor. During an interview on 12/8/2022 at 11:25 AM, the Housekeeper (HK) stated that on 11/24/2022 at around 8:30 AM he was in the hallway near Resident 1’s room. The HK stated he witnessed CNA 1 grab Resident 1 by the collar and physically push Resident 1 into the resident’s room. He stated he was not able to see anything after they entered the room. The HK stated he asked Resident 2 if he saw what happened with Resident 1 and Resident 2 stated he saw CNA 1 grab and push Resident 1 into the room. The HK stated he informed the Receptionist of what occurred. During an interview on 12/8/2022 at 11:40 AM, Resident 2 stated that on 11/24/2022 at around 8 or 9 AM, he saw CNA 1 grab Resident 1 on the back of her gown around the collar and push Resident 1 into her room. Resident 2 stated Resident 1 did not fall. Resident 2 stated if CNA 1 grabbed and pushed him like she did Resident 1, he would feel sad and afraid. A review of Resident 2’s admission record indicated the facility admitted Resident 2 on 7/28/2022 with diagnoses including Schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension), and hypertension (HTN - elevated blood pressure). A review of the Resident 2’s MDS, dated 11/1/2022, indicated Resident 2 was cognitively intact (decisions consistent or reasonable). During an interview on 12/8/2022 at 11:50 AM, the Director of Staff Development (DSD) stated that on 11/24/2022 at around 9:30 AM she was informed of the incident. She stated she spoke with CNA 1 and CNA 1 stated she did not push the resident but did grab Resident 1’s gown by the neck. The DSD stated CNA 1 was sent home immediately that day on 11/24/2022 pending the investigation. The DSD stated she spoke with the HK and the RCT, who validated and collaborated they witnessed CNA 1 grabbed and pushed Resident 1 into the room. The DSD stated pushing and grabbing a resident can be considered a form of physical abuse. During an interview on 12/8/2022 at 12 PM, Resident 1 stated she did not remember being grabbed by the collar by CNA 1, but stated she was pushed in the back in the morning by CNA 1. Resident 1 stated she could not remember what day it happened and that she felt ok. During an interview on 1/24/2023 at 10:23 AM, CNA 1 stated she was working on 11/24/2022 from 7 AM to 3:30 PM shift. CNA 1 stated she was assigned to care for Resident 1 and was walking in the hallway when she helped Resident 1 with her gown because it was slightly opened. She stated the backside was open, so she tied the gown. CNA1 stated she directed the resident back to her room by putting both her hands on both of Resident 1’s right and left shoulders. She stated she guided and did not push the resident to her room and put the resident back to her bed. CNA1 stated the DSD called her after she left Resident 1’s room and indicated she needed to go home due to allegedly pushing Resident 1. She stated while she was transferring resident from hallway to her room, there was no additional staff with her. She stated Resident 1 was ambulatory and able to follow directions and required limited assistance while walking. When CNA 1 was asked why she stood behind Resident 1 when Resident 1 was ambulatory, followed directions, and required limited assistance while walking, CNA 1 stated she was standing behind the resident to cover Resident 1’s gown. CAN1 stated she was grabbing Resident 1’s gown and not holding onto both her shoulders to cover resident’s open gown in the back. On 1/24/2023 at 11:21 AM, during an interview, the Director of Nursing (DON) stated the facility conducted a thorough investigation and concluded CNA 1 conducted inappropriate handling of Resident 1. The DON stated the investigation substantiated the allegation of physical abuse that occurred on 11/24/2022 between Resident 1 and CNA 1. She stated CNA 1 held Resident 1 by her gown collar. The DON stated staff were trained to guide residents while holding their hands versus holding residents by the shoulder or collar of the clothes. She stated staff were trained to hold residents who have difficulty walking by the hand to assist and if necessary to grab residents by the waist. The DON stated the conclusion of the investigation indicated CNA 1 did not follow facility protocol in properly transferring residents by grabbing Resident 1 by the back of the collar and pushing resident from the back. She stated CNA 1 grabbing and pushing Resident 1 can potentially be considered physical abuse. She stated the staff was terminated from the facility and reported to her licensing board for abuse. The DON stated an average cognitively intact resident would be very upset with being grabbed and pushed into the room. She stated the resident could potentially experience emotional distress from the incident. During an interview on 1/24/2023 at 2:07 PM, the Administrator (Admin) stated the grabbing of the resident by the back of the collar and pushing the resident can be considered a form of abuse. He stated when the facility was informed of the incident, the staff was sent home immediately, and appropriate authorities notified including the ombudsman, police, and local CPDH. He stated after the facility investigated the incident, CNA 1 was determined to be in violation of the facility abuse policy and procedure and was terminated and reported to the licensing board for abusive behavior towards Resident 1. He stated a cognitive intact person or reasonable person who was intact would not like to be grabbed by the collar and pushed by a staff. He stated they may have felt frustrated, angry, and even fearful. A review of the facility’s policy and procedure titled, “Abuse Prevention Program,” revised 12/2016, indicated residents have a right to be free from abuse. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, or physical abuse. The policy indicated as part of the resident abuse prevention, the administration will develop and implement policies and procedure to aid our facility in preventing abuse, neglect, or mistreatment of our residents. The facility failed to protect the resident’s right to be free from physical abuse when CNA 1 grabbed the back collar of Resident 1’s gown and pushed Resident 1 into the resident’s room. As a result, on 11/24/2022, Resident 1 was evaluated for injury and distress, and was at risk for negative psychological impact due to alleged physical abuse. A reasonable person would have suffered emotional distress such as becoming fearful and suffer psychosocial harm when remembering the incident. The above violation had a direct or immediate relationship to the health, safety, and security of Resident 1.