Health inspection·January 14, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation(b)(1) (b) The facility must develop and implement written policies and procedures that: (b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. 22 CFR § 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 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. 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. On 12/9/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding a resident-to-resident altercation. On 12/16/2024, the CDPH made an unannounced visit to the facility to investigate the FRI. The facility failed to: 1. Ensure the facility’s Abuse Prevention policy and procedure (P&P) was implemented when Certified Nursing Assistant (CNA) 1 failed to immediately report a verbal resident-to-resident altercation, on 12/8/2024, between Resident 9 and Resident 10, to the supervising licensed nurse. As a result, Resident 9 was left in Room A with Resident 10, where Resident 10 repeatedly struck Resident 10 in the face. Resident 9 sustained pain to her head and face and verbalized fear of further abuse. Resident 9 was a 79-year-old female, admitted to the facility on 5/5/2023 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness), generalized muscle weakness, and Poly osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). A review of Resident 9’s Minimum Data Set (MDS, a resident assessment tool), dated 11/12/2024, indicated Resident 9 had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 9 could not move on her own and was dependent on staff for mobility while in and out of bed. Resident 10 was a 77-year-old female, originally admitted to the facility on 7/31/2024, and was most recently re-admitted on 12/4/2024 with diagnoses including anxiety disorder (a condition that causes excessive worry, fear, dread, and uneasiness), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), cognitive communication deficit, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). A review of Resident 10’s MDS, dated 11/7/2024, indicated Resident 10 had moderate cognitive impairment. The MDS indicated Resident 10 could independently get in and out of bed and could walk around her room and the facility without requiring assistance from staff. A review of Resident 9’s Change of Condition (COC) Assessment, dated 12/8/2024, indicated an unspecified staff member reported to Registered Nurse (RN) 1 that Resident 9 was observed being repeatedly struck in the face by Resident 10. The assessment indicated RN 1 separated and assessed Resident 9 and Resident 10. During an interview on 12/16/2024 at 3:07 PM, RN 1 stated on 12/8/2024, CNA 1 reported a physical altercation between Resident 9 and Resident 10. RN 1 stated she immediately went to Room A after receiving report of the altercation. RN 1 stated upon arrival to Room A, Resident 9 was repeatedly stating she wanted Resident 10 to be kept away from her. RN 1 stated Resident 10 was still in Room A. RN 1 stated she did not recall any staff in Room A when she arrived. RN 1 stated that if a CNA observed or became aware of an incident of verbal or physical resident abuse, it was to be reported to her immediately. RN 1 stated prompt reporting by the CNA would allow necessary interventions to be carried out right away to ensure the safety of the residents. During an interview on 12/16/2024 at 2:22 PM, CNA 1 stated that on 12/8/2024, in the late afternoon, she overheard a verbal altercation from outside Room A, between Resident 9 and Resident 10. CNA 1 stated she entered Room A and Resident 10 told her nothing happened. CNA 1 stated she then left Room A and overheard a second verbal altercation a few minutes later between Resident 9 and Resident 10 from the hallway. CNA 1 stated she entered Room A, a second time and observed Resident 10 standing at Resident 9’s bedside. CNA 1 stated she observed Resident 10 repeatedly hitting Resident 9 in the face. CNA 1 stated she told Resident 10 to stop hitting Resident 9 and told Resident 10 she was not allowed to hit Resident 9. CNA 1 stated she then left Room A and returned to patient care for another resident. CNA 1 stated she did not immediately report the altercations to her supervising licensed nurse. CNA 1 stated she overheard a third verbal altercation between Resident 9 and Resident 10 a few minutes later. CNA 1 stated she entered Room A, a third time and observed Resident 10 at Resident 9’s bedside. CNA 1 stated Resident 10 looked “threatening” and was planning to strike Resident 9 again. CNA 1 stated after the third altercation, she reported the observed abuse to RN 1. CNA 1 stated abuse of any type was to be reported to the Charge Nurse or Registered Nurse immediately for the safety of the residents. CNA 1 stated she did not report immediately because Room A was not assigned to her care on the schedule. During an interview on 12/18/2024 at 9:16 AM, the Director of Staff Development (DSD) stated she was responsible for educating and training staff related to abuse prevention, identification, and reporting. The DSD stated all staff were responsible for the safety of all facility residents, regardless of the staff assignments. The DSD stated if a CNA was aware of or directly witnessed an incident of abuse, the incident was to be reported to the Licensed Vocational Nurse (LVN) Charge Nurse or RN immediately. The DSD stated the task of reporting should not be delegated to another staff member. The DSD stated that delayed reporting created a delay in the implementation of staff interventions to prevent further abuse from occurring. The DSD stated delayed reporting created additional opportunities for the aggressor to continue to hurt or harm the victim. During an interview on 12/18/2024 at 2:09 PM, the Director of Nursing (DON) stated all facility staff were mandated reporters and were to report any incidents of abuse immediately. The DON stated it did not matter if the abuse involved residents that were not assigned to the staff member who witnessed the abuse. The DON stated the staff who observed the abuse was the staff member required to report it. The DON stated resident safety was a priority, and stated prompt reporting was important for prevention of further abuse. The DON stated residents involved in a resident-to-resident altercation were not to be left alone together following an incident of abuse. The DON stated that if left alone, another altercation could occur, with potential physical and psychosocial harm to the residents. A review of the facility’s undated job description for a CNAs, indicated CNAs reported to the Charge Nurse. The job description indicated CNAs were to report any resident abuse to the Charge Nurse immediately. A review of the facility P&P titled “Abuse Prevention and Management”, dated 6/12/2024, indicated abuse included verbal and physical abuse. The P&P indicated staff were to identify, correct, and intervene in situations where abuse was likely to occur. A review of the facility P&P titled “Abuse Reporting and Interventions”, dated 1/2024, indicated staff were to ensure that all incidents of resident abuse were reported promptly. A review of the facility P&P titled “Resident-to-Resident Altercations”, dated 11/2015, indicated that to protect the health and safety of facility residents, staff were to observe residents for aggressive or inappropriate behavior toward other residents, and if observed, report the behaviors promptly to the Charge Nurse, Director of Nursing Services, and Administrator. A review of the facility P&P titled “Resident Safety”, dated 4/2021, indicated it was the facility policy to provide a safe and hazard free environment. The P&P indicated any facility staff who identified an unsafe situation was to immediately notify their supervisor or Charge Nurse. The facility failed to: 1. Ensure the facility’s abuse prevention P&P was implemented when CNA 1 failed to immediately report a verbal resident-to-resident altercation, on 12/8/2024, between Resident 9 and Resident 10, to the supervising licensed nurse. As a result, Resident 9 was left in Room A with Resident 10, where Resident 10 repeatedly struck Resident 10 in the face. Resident 9 sustained pain to her head and face and verbalized fear of further abuse. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.