Other·January 27, 2023

On 11/23/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation about Resident to Resident abuse. The facility failed to protect the residents right to be free from physical abuse for two of three sampled residents (Residents 1 and 3) by failing to ensure: 1. Resident 2 did not hit the back of Resident 1's head and slammed Resident 1's wheelchair (WC) into a bedframe. 2. Resident 2 did not take Resident 3's snacks, computer, and or personal belongings. As a result, Resident 1 became very upset and suffered physical pain of 6/10 (numerical pain assessment tool where zero is no pain and 10 is the worst pain) to his legs and was at risk for psychosocial (mental health) harm. Resident 3 yelled for help and felt her personal belongings were unsafe in the facility. A review of Resident 1's Admission Record (face sheet) indicated the facility admitted Resident 1 on 9/2/2022 with diagnoses including cerebral infarction (a lack of adequate blood supply to brain, deprives brain of oxygen and vital nutrients which can cause parts of the brain to die off), functional quadriplegia (partial or total loss of use of all four limbs and torso), and hypertension (high blood pressure). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/8/2022, indicated Resident 1 had the ability to make decisions and be understood. The MDS indicated Resident 1 required extensive staff assist with transfers from bed and one-person physical assist for activities of daily living (ADLs - bed mobility, transfers from bed, toilet use, and personal hygiene). The MDS further indicated Resident 1 had impairment on one side of his upper and lower extremities. The MDS indicated Resident 1used a WC for mobility. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- communication technique between the health care team) form, dated 11/18/2022 timed at 1:30pm, indicated Resident 1 complained of left leg pain 6/10 (numerical pain assessment tool where zero is no pain and 10 is the worst pain) at 1:45pm and was administered Tramadol (strong pain medication) 50 mg (milligrams - unit dose measurement) 1 (one) tab (tablet) for the left leg pain. The SBAR further indicated Resident 1 claimed another resident slapped the back of his head while sitting in his WC inside his room. The SBAR further indicated the nurses heard Resident 1 scream and immediately separated the other resident (Resident 2) from Resident 1. The SBAR further indicated Resident 1 was assessed from head to toe, and no swelling noted on back of his head, no discoloration, or open skin. The SBAR indicated Resident 1 denied pain on back of his head but was very upset about the incident. A review of Resident 1's Medication Administration Record (MAR) for the month of 11/2022, indicated Resident 1 received Tramadol 50 mg as needed for 6/10 (moderate to severe) pain level on 11/18/2022 at 1:45 pm. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 8/23/2022 with diagnoses including dementia (loss of memory, thinking and reasoning), with other behavioral disturbance, psychosis (a severe mental disorder), schizophrenia (a serious mental disorder in which people interpret reality abnormally) and anxiety (nervousness) disorder. A review of Resident 2's MDS dated 8/30/2022, indicated Resident 2 had severely impaired cognition (mental ability) for daily decision making and could not be understood. The MDS indicated Resident 2 had no potential for psychosis (a severe mental disorder). A review of Resident 2 's SBAR form, dated 11/18/2022 at 3:53pm, indicated Resident 2 was walking in the hall and apparently was pushing a resident's (Resident 1) WC without Resident 1's permission on 22/28/2022 at 2:00pm. The SBAR also indicated Resident 2 slapped the back of the resident's (Resident 1) head. The SBAR further indicated Resident 2 "was very angry and confused as to what was happening in this situation." A review of Resident 2's IDT (Interdisciplinary Team- a team of professionals who plan, coordinate, and deliver personalized health care) notes dated 11/18/2022 timed at 4:58pm, indicated IDT met and discussed the incident where Resident 2 was accused of allegedly pushing another resident's (Resident 1) WC from behind accidentally hitting the "footrest against the bed then slapping the same resident at back of head creating risk of injuries to self and others." A review of Resident 2's Initial Psychologist (a professional specializing in diagnosing and treating diseases of the brain, emotional disturbance, and behavior) Assessment, dated 11/23/2022, indicated Resident 2 "clearly meets medical necessity based on symptoms (e. g., behavioral disturbances, psychosis, anxiety, dementia), diagnosis and overall clinical presentation. Psychosis is dementia related in nature. The Psychologist's report further indicated Resident 2 "continues to present with symptoms that warrant clinical attention (e.g., behavior disturbances, psychosis, dementia). The recommendations included "psychiatric treatment as needed." A review of General Acute Care Hospital (GACH) records titled, "Hospital Physician H&P" (History and Physical) for Resident 2, dated 11/20/2022 timed 12:20pm, indicated Resident 2 was noted with increased aggressive and hostile behavior and appeared to be paranoid (a mental disorder in which a person has an extreme fear and distrust of others). The H&P report further indicated Resident 2 presented altered with aggression. A review of GACH records titled, "Psychiatric (medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders including those related to mood, behavior, cognition, and perceptions) Evaluation" for Resident 2 dated 11/21/2022, indicated Resident 2 was admitted to the GACH on 11/21/2022 due to altered mental status and aggressive behavior. The GACH notes also indicated "The patient (Resident 2) is confused, disorganized, forgetful with impaired insight and judgment ... patient wanders in the unit, goes into other peers' rooms, very confused and slow to follow redirection. Currently, the patient is overly anxious and unable to relax." The psychiatric evaluation report further indicated Resident 2 would benefit from psychiatric care for titration (medication started at a low dose) of psychotropic medication (medications that affects a person's mind, thoughts, and function). A review of Resident 3's Admission Record indicated the facility initially admitted Resident 3 on 4/20/2022 and was readmitted on 10/12/2022 with diagnoses including mechanical complication of internal left knee prothesis (a device, such as an artificial leg, that replaces a part of the body), abnormalities of gait and mobility, lack of coordination, functional quadriplegia (partial or total loss of use of all four limbs and torso [trunk]), major depressive disorder (a persistent feeling of sadness and loss of interest), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 3's MDS dated 10/27/2022, indicated Resident 3 had the ability to make decisions and be understood. The MDS indicated Resident 3 required extensive staff assist with transfers from bed and one-person physical assistance for ADLs. The MDS further indicated Resident 3 had impairment on one side of her lower extremity and used a WC for mobility. On 11/23/2022, at 9:30 am, during an interview, Resident 1 stated on 11/18/2022 afternoon, he was sitting in his WC in his room, watching television, when Resident 2, came inside his room and tried to steal his candy. Resident 1 stated "this was the third time he (Resident 2)" came into his room to take his candy. Resident 1 stated, Resident 2 snuck behind him (Resident 1) and hit him in the back of his head. Resident 1 stated he yelled for help and tried to grab and hold Resident 2, but he could not reach him. Resident 1 stated Resident 2 took his WC and slammed his (Resident 1) legs against Resident 1's bedframe bed. Resident 1 stated he experienced pain after the incident and the nurses administered him pain medication. Resident 1 stated Resident 2 walks around the facility like a zombie (a person who is or appears to be lifeless, apathetic, or totally lacking in independent judgment) and wished Resident 2 would stop coming into his room and take his personal belongings. On 11/23/2022, at 10:08 am, during an interview, Resident 3 stated Resident 2 came in her room and tried to take her snacks and computer. Resident 3 stated, she had to yell for help for staff to come and get Resident 2 out of her room. Resident 3 stated, the last time Resident 2 came into her room was two weeks ago and tried to take her personal belongings. Resident 3 stated, "The staff don't do anything. Resident 2 is a thief." Resident 3 sated she felt her personal belongings are not safe. Resident 3 stated Resident 2 constantly walked around the facility unsupervised. On 11/23/2022, at 10:40 am, during an interview, Certified Nurse Assistant 1 (CNA 1) stated on Friday 11/18/2022 at around 2 pm, she heard Resident 1 scream and saw Resident 2 "smack" (hit) Resident 1 in the back of the head. CNA 1 stated the RN Supervisor, and the Physical Therapist Assistant (PTA) came and removed Resident 2's hands from Resident 1's WC. CNA 1 stated Resident 2 is strong. CNA 1 stated Resident 2 gets angry and does not know when to talks to him. CNA 1 stated there is no easy way to control Resident 2 when he was in a bad mood. On 11/23/2022, at 12 pm, during an interview, the SSD stated, she has told the Administrator (ADMIN) and the Director of Nursing (DON) her concerns about Resident 2 remaining in the facility. The SSD stated she reported to the Administrator, and the DON that Resident 2 tried to grab Resident 8's cell phone and "they (ADMIN and DON) have not done anything." On 11/23/2022, at 12:30 pm, during an interview, the PTA stated he heard shouting from Resident 1's room while he was in the Rehabilitation (Rehab- physical therapy) room. Resident 2 would not let go of Resident 1's chair until he removed Resident 2 from the Resident 1's WC. The PTA stated he has witnessed Resident 2 become aggressive when the nurses try to change his clothes. The PTA stated Resident 2 wanders around the facility. On 11/23/2022, from 1:17pm to 1:22pm, during an observation, Resident 2 was walking in the hallway unsupervised. No staff observed in the hallways and no nursing station observed near the hallway. On 11/23/2022, at 1:26 pm, during a concurrent interview and record review with the MDS nurse, Resident 2's medical chart was reviewed. The MDS nurse stated a psychiatrist did not see Resident 2 for the month of 10/2022. Resident 2 care plans were also reviewed. The MDS nurse confirmed and stated the facility did not develop care plans to address Resident 2's wandering behavior into other residents' rooms and or taking other residents belongings. The MDS nurse stated she could not find/locate any documentation that addressed previous incidents whereby Resident 2 tried taking other residents belongings. On 11/23/2022, at 3:04 pm, during an interview, the DON stated the incident between Residents 1, 2, and 3 was preventable if the facility staff watched Resident 2 more closely and frequently. The DON confirmed and stated Resident 2 did not have a care plan including interventions to address his behaviors of "going in and out of resident rooms and trying to take their belongings." On 11/23/2022, at 3:45 pm, during an interview, the ADMIN stated the facility completed the 5-Day report and investigation and concluded that the abuse allegation between Residents 1 and 2 was substantiated. On 11/23/2022, at 4:30 pm, during an interview, the facility's Psychologist stated Resident 2 required a psychiatrist (medical doctor who specializes in mental health, including substance use disorders and are qualified to assess both the mental and physical aspects of psychological problems) to manage the residents' behavior. The Psychologist further stated, "if the facility was unable to control Resident 2's behavior, he (Resident 2) should be transferred to a psych facility (Psychiatry - also known as mental health hospitals, behavioral health hospitals, are hospitals or wards specializing in the treatment of severe mental disorders) or somewhere where he can be better controlled." On 11/29/2022, at 11:41 am, during an interview, CNA 4 stated she has reported Resident 2's abusive behavior to the DON, and "she (DON) will not do anything." On 11/29/2022, at 12:39 pm, during an interview, the ADMIN stated, "the facility is working on hiring registry so Resident 2 can have one-to-one (1:1- health care support worker whose role it is to provide one to one nursing or observation care to an individual patient) supervision at all times." A review of the facility's Policy and Procedures (P&P) titled, "Abuse and Mistreatment of Residents," dated, 2/2016, indicated to uphold a Resident Right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary punishment. The P&P further indicated, "Abuse is defined as the willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being." A review of the facility's undated Policy and Procedures (P&P) titled, "Management of Acute Aggressive Episodes," indicated to protect the residents and staff from harm. while bringing aggressive incidents and occurrences under control. If the resident is a threat to himself or others, or if the episode may be repeated, initiate a discharge to an appropriate facility. A review of the facility's undated P&P titled, "Aggressive Acting Out," indicated, the interdisciplinary team will then assess resident's behavior, develop a plan of care with appropriate interventions related to these behaviors in the following manner: a. Identify the problem behavior b. Gather information. Develop plan of care based on assessment and in consultation with interdisciplinary team. The Residential Care plan will be reviewed and updated within a reasonable time frame determined by the IDT. Behavioral intervention strategies will be the primary consideration when determining a plan of care. The IDT will continue to monitor and review the resident's behavior and related care plan on a timely basis until the problem is resolved. A review of the facility's undated P&P titled, "The Resident Care Plan," indicated the care plan generally includes identification of medical, nursing, and psychosocial needs. Reassessment and change as needed to reflect current status. Team floor conference should be conducted at regular intervals. Problems should be discussed and entered on the plan. A review of the facility's undated P&P titled, "Physician Psychotherapeutic Intervention Progress Note," indicated Environmental Behavioral therapy approaches attempted included appropriate room placement, activity plan, and one-to-one (1:1) room visit. The facility failed to protect the residents right to be free from physical abuse for two of three sampled residents (Residents 1 and 3) by failing to ensure: 1. Resident 2 did not hit the back of Resident 1's head and slammed Resident 1's wheelchair (WC) into a bedframe. 2. Resident 2 did not take Resident 3's snacks, computer, and or personal belongings. As a result, Resident 1 became very upset and suffered physical pain of 6/10 (numerical pain assessment tool where zero is no pain and 10 is the worst pain) to his legs and was at risk for psychosocial (mental health) harm. Resident 3 yelled for help and felt her personal belongings were unsafe in the facility. The above violations had a direct relationship to the health, safety, and security of Residents 1 and 3.