Health inspection·December 27, 2024

42 CFR §483.12(a)(1) Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. 22 CCR §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. 22 CCR §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 11/18/2024, The California Department of Public Health (CDPH) received a Facility Reported Incident for a resident-to-resident altercation alleging Resident 2 punched Resident 1 in the face. On 11/18/2024, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Ensure Resident 1 was free from physical abuse. 2. Implement its Policy and Procedure (P&P) titled “Abuse Prevention and Management” which indicated the facility will identify, correct, and intervene in situations in which abuse of a resident was more likely to occur. As a result, Resident 1 was punched in the face by Resident 2 and sustained discoloration to the nose and a scratch under her right eye. a. Resident 1 was a 62-year-old female initially admitted to the facility on 9/25/2024 and readmitted on 11/9/2024, with diagnoses of schizophrenia (a chronic mental disorder that affects a person’s ability to think, perceive, and interact with others) and dementia (a progressive state of decline in mental abilities). A review of Resident 1’s Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2024, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required supervision by staff when walking, dressing, and personal hygiene. A review of the History and Physical (H&P) dated 11/9/2024, indicated Resident 1 had a fluctuating capacity to understand and make decisions. A review of Resident 1’ s Change of Condition (COC) dated 11/18/2024, indicated on 11/18/2024, Resident 1 had behavioral symptoms of agitation (feeling of unease) and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). The COC indicated Resident 1’s physician was notified. The COC did not indicate any new physician orders or interventions were done. A review of Resident 1’s “Skin Check,” dated 11/18/2024, indicated Resident 1 had discoloration to the nose and a scratch under the right eye. During an interview on 11/18/2024 at 4:00 p.m. the Director of Nursing (DON) stated when Resident 1 wandered into Resident 2’s room , Resident 2 was hit by Resident 1 and could have been seriously hurt. b. Resident 2 was a 70-year-old male initially admitted to the facility on 12/29/2023 and readmitted on 6/17/2024 with diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety disorder (a mental disorder characterized by feelings of worry or fear) and, depression (a mental illness that involves a persistent low mood and loss of interest in activities). A review of Resident 2’s H&P, dated 6/17/2024, indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's MDS, dated 10/6/2024, indicated Resident 2 was able to understand and be understood. The MDS indicated Resident 2 was independent when walking, dressing, and with personal hygiene. A review of Resident 2’s care plan, titled “Behavior problem related to unpredictable mood changes from calm to anger, by using intimidating body gestures towards other,” dated 11/4/2024, indicated Resident 2 will have no evidence of behavior problems. The care plan interventions included frequent visual monitoring for the safety of Resident 2 and others. The care plan indicated to intervene as necessary to protect the rights and safety of others. A review of Resident 2’s “Change of Condition,” (COC) dated 11/18/2024, indicated on 11/18/2024 Resident 2 punched Resident 1 in the nose causing Resident 1 to fall. During an interview on 11/18/2024 at 12:22 p.m., Resident 2 stated he punched Resident 1 in the face because Resident 1 came into his room during the night. Resident 2 stated he thought Resident 1 had a knife so he punched Resident 1 in the face. During a concurrent interview and record review on 11/18/2024 at 3:45 p.m., with Registered Nurse 1 (RN 1), Resident 2’s care plan, titled “Behavior problem related to unpredictable mood changes from calm to anger, by using intimidating body gestures towards others,” dated 11/4/2024 was reviewed. RN 1 stated the care plan indicated Resident 2 would have no evidence of behavior problems. RN 1 stated she previously witnessed Resident 2 ball up his fist when frustrated and had altercations with other residents. During an interview on 11/18/2024 at 4:10 p.m., the DON stated Resident 2 had schizophrenia and his aggressive behaviors had become worse. The DON stated Resident 2 thought other residents were going to harm him. The DON stated Resident 2 had previous verbal and physical altercations with other residents over the last few months. The DON stated when Resident 1 wandered into Resident 2’s room it did not give him (Resident 2) the right to hit Resident 1. During an interview on 11/18/2024 at 4:30 p.m., the Administrator (ADM) stated Resident 1 and Resident 2 were confused and the staff needed to monitor them both. The ADM stated Resident 2 had delusional (having false or unrealistic beliefs) thoughts and when Resident 1 went into Resident 2’s room Resident 1 could have been hurt. A review of the facility’s policy and procedure (P&P), titled “Abuse Prevention and Management, dated 6/2024, indicated physical abuse is defined as but not limit to, hitting, slapping, punching, and/or kicking. The P&P indicated the facility will identify, correct, and intervene in situations in which abuse of a resident is more likely to occur. The facility failed to: 1. Ensure Resident 1 was free from physical abuse. 2. Implement its Policy and Procedure (P&P) titled “Abuse Prevention and Management” which indicated the facility will identify, correct, and intervene in situations in which abuse of a resident was more likely to occur. As a result, Resident 1 was punched in the face by Resident 2 and sustained discoloration to the nose and a scratch under her right eye. This violation had a direct or immediate relationship to the health, safety, or security of residents.