Other·June 14, 2023

On May 3, 2023, 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 resident's right to be free from physical abuse for Resident 3 in accordance with the facility's policy and procedures, dated June 2022, by failing to: 1. Ensure Resident 4 did not push Resident 3 on April 29, 2023. 2. Implement safety measures to protect Resident 3 from potential further physical abuse from Resident 4 by not sharing or remain in the same room after the incident on April 29, 2023. 3. Ensure Licensed Vocational Nurse 4 (LVN 4) implemented the facility's abuse policy and procedures to protect Resident 3 from further potential harm or abuse. These deficient practices resulted in Resident 4 subjecting Resident 3 to physical abuse and mental abuse. Resident 3 fell to the ground, hit her head on the floor, and bled from the mouth after she was pushed by Resident 4. Resident 3 was visibly anxious and stated she feared for her life and could die if Resident 4 pushed her again. A review of Resident 3's admission record indicated the facility admitted Resident 3 on April 1, 2023, with diagnoses including Type 2 diabetes mellitus, (A long term condition that affects the way the body processes blood sugar), unsteadiness on feet, lack of coordination, dysphagia (Swallowing difficulties), and cataract (A condition where the lens of the eye becomes cloudy). A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated April 8, 2023, indicated Resident 3's cognitive skills (mental ability to make decisions of daily living) was intact, and was able to understand, and communicate her needs. The MDS indicated Resident 3 required staff assist when moving from seated to standing position, walking, turning around, moving on and off toilet, surface to surface transfer, for activities of daily living (ADL- grooming, bed mobility, personal hygiene, surface transfers) and had unsteady balance/gait (manner of walking). The MDS indicated Resident 3 required staff assist with mobility due to weakness in both arms. The MDS further indicated Resident 3 did not have any behavioral concerns/issues. The MDS indicated Resident 3 did not have any thoughts of hurting self. The MDS did not indicate that Resident 3 felt she was better off dead. A review of Resident 3's Psychiatry (The branch of medicine that deals with mental and behavioral disorders) and Neurology (The branch of medicine that deals with disorders of the nervous system) consultation progress notes dated April 29, 2023, indicated the psychiatrist consulted with Resident 3 via videoconference. The progress notes indicated, "Psychiatry consult request as patient (Pt- Resident 3) is throwing herself on floor and falsely accusing peers and staff of assaulting her." The progress notes indicated Resident 3 did not have a history (hx) of schizophrenia (A mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) or psychosis (A mental health problem that causes people to perceive or interpret things differently from those around them). The progress notes indicated Resident 3 told the psychiatrist, "I don't have problems," denied falsely accusing others, and denied throwing herself to the floor. The psychological consultation notes further indicated, Resident 3, "Denies she is accusing others of harming her. Also denies falling on the floor." A review of Resident 3's Change of Condition Evaluation (COC- A sudden change in mental, physical, or behavioral status from a resident's normal status) report dated April 29, 2023, timed at 12 midnight, indicated LVN 4 documented that Resident 3 was, "making false accusations towards resident and staff." The COC also indicated Resident 3's mental status was unchanged from baseline. A review of Resident 3's nursing progress notes dated, April 29, 2023, timed at 12:28 a.m., indicated that on April 28, 2023, at 11:30 p.m., "Patient [Resident 3] noted to be at nurses station speaking to the charge nurse (CN) about her roommate [Resident 4] being too loud." A review of Resident 3's Psychiatry and Neurology consultation progress notes dated May 3, 2023, indicated the psychiatrist documented that Resident 3 stated, "That .... Is crazy." Resident 3 was, "Visibly anxious states she was pushed by roommate [Resident 4]. ... Repeating she [Resident 4] pushed me. ... "No criteria for 5150 (The Welfare and Institutions Code number, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disable) met. Recommend room change..." A review of Resident 3's Skilled Medicare Charting Record (SMCR), dated April 28, 2023, timed at 11:07 p.m., indicated Resident 3 was, "alert and understands the situation, and is able to communicate with clear speech." A review of Resident 4's record titled Room Change Form, dated April 29, 2023, timed at 8:59 a.m., indicated Resident 4 remained in the room with Resident 3. A review of Resident 4's admission record indicated the facility admitted Resident 4 on April 4, 2023, with diagnoses including unspecified psychosis (A severe condition in which thought and emotions are so affected that contact is lost with external reality), schizophrenia (A mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and anxiety disorder (tension, or uneasiness that stems from the anticipation of danger, which may be internal or external). The admission record further indicated Resident 1's diagnoses included insomnia (A sleep disorder in which a person has trouble falling and/or staying asleep), and psychoactive substance (Is a chemical substance that changes function of the nervous system, and results in alterations in perception, mood, cognition and behavior) abuse with unspecified psychoactive substance-induced disorder. A review of Resident 4's MDS dated April 11, 2023, indicated Resident 4 did not have impaired cognitive skills. Resident 4, able to walk independently with minimal assistance and supervision from staff. On May 2, 2023, at 1:20 p.m., during an interview, Resident 3 stated she informed LVN 3 that she [Resident 3] fell to the ground after Resident 4 pushed her. Resident 3 stated that LVN 3 assessed her, and that during the assessment, she [Resident 3] informed LVN 3 that Resident 4 pushed her to the floor. Resident 3 further stated LVN 3 ignored her report about the incident with Resident 4. Resident 3 stated she was terrified that she could die if Resident 4 pushed her again. Resident 3 stated that she did not know how to protect herself. Resident 3 stated that she told LVN 3 that Resident 4 pushed her. Resident 3 further stated that LVN 3 ignored her [Resident 3] statement that Resident 4 pushed her. Resident 3 stated LVN 3 told her to stand from the floor and go wash her [Resident 3] face in the restroom. On May 2, 2023, at 1:34 p.m., during an interview, Resident 4 stated she pushed Resident 3 to the ground. Resident 4 also stated that a facility staff told her on the night of the incident with Resident 3, "that everything would be okay, and not to worry." Resident 4 refused to provide more details concerning the conversation with the facility staff that reassured her. Resident 4 also declined to identify the facility staff who told her that everything would be alright. On May 3, 2023, at 7 a.m., during an interview, LVN 4 stated that on the evening of April 29, 2023, Resident 3 reported to him [LVN 4] that Resident 4 pushed her. LVN 4 stated he found Resident 4 asleep after Resident 3 reported the incident with Resident 4. LVN 4 stated Resident 3's allegation about Resident 4 was unsubstantiated (Not supported or proven by evidence). LVN 4 stated he did not implement any abuse policy and procedures to protect Resident 3 from further potential harm or abuse. LVN 4 stated Resident 4 slept all night, on April 29, 2023. LVN 4 stated further he was not familiar with Resident 3 and that he had never provided care to Resident 3. On May 3, 2023, at 10:07 a.m., during an interview, LVN 3 stated that she witnessed Resident 3 throw herself to the floor and bled from the mouth. LVN 3 stated she witnessed Resident 3 fall to the floor and hit her [Resident 3's] head on the floor. LVN 3 stated she instructed Resident 3 to stand up, go to the restroom and wash her [Resident 3] mouth and face, so that LVN 3 could better assess Resident 3. LVN 3 stated Resident 3 refused to comply with LVN 3's instructions. LVN 3 stated she did not implement the facility's abuse policy and procedures because LVN 3 stated she was in the supply closet and witnessed Resident 3 throw herself to the ground. On May 3, 2023, at 10:27 a.m. during an observation, Resident 3's room was not directly in front of the supply closet. On May 3, 2023, at 12:20 p.m., during an interview with Resident 3 in the presence of the Social Services Director (SSD), Resident 3 stated that her roommate [Resident 4] pushed her on April 29, 2023. The Social Services Director (SSD) stated she understood everything Resident 3 said. A review of the facility's document titled, "Employee Interview Record," dated May 3, 2023, timed at 2 p.m., indicated the Director of Nursing (DON) documented that LVN 3 stated Resident 3, "Went to the other LVN about how she can't sleep due to roommate being loud. ... LVN was at the central supply room and heard someone yelling and noted resident threw herself onto the floor. ... and noted there was bleeding. ... LVN placed a four by four (4x4) gauze (wound care material) on resident's lip..." A review of the facility's document titled, "Employee Interview Record," dated May 3, 2023, timed at 2 p.m., indicated the DON documented that LVN 4 stated that Resident 3, "came to the station and requested to move the roommate [Resident 4] out of the room. ..." The employee interview record indicated Resident 3 reported that, "She [Resident 4] is not good. I want her out of the room." A review of the facility's document titled, "Resident Interview Record," dated 5/3/2023, indicated the SSD documented that Resident 4 stated, "She [Resident 4] was slamming the door to the room. ... All I remember was closing the door and she [Resident 3] fell. ... LVN [LVN 4] was in the hallway and saw [Resident 3] on the floor by her room. ... LVN [LVN 4 assessed her [Resident 3] and noted bleeding from the upper lip that looked like resident bit her lip. ..." A review of the facility's document titled, "Resident Interview record," dated 5/3/2023, indicated the SSD documented that Resident 3 stated, "Verbalized Friday evening (4/28/2023) roommate [Resident 4] was pacing and not allowing her to rest. Reported to nurses' station, resulting in one of the charge nurses (LVN) to speak to roommate." Resident 3 alleged to be pushed ... A review of the facility's policy and procedures, titled, Resident to Resident Altercation," released in December 2017, indicated, "Fundamental Information: All altercations, including those that may represent resident-to-resident abuse, shall be thoroughly investigated and reported to the Nursing Supervisor, the Director of Nursing services and to the Administrator. Procedure: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents. ... incidents shall be promptly reported to the Nurse Supervisor, the Director of Nursing services and to the Administrator." A review of the facility's policy and procedures (P&P), dated June 2022, titled, "Abuse and Neglect Prohibition Policy," indicated, "... It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents through the following: ...; Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Reporting of incidents, investigations, and the facility's response to the results of their investigations; protection of residents during investigations." The P&P further indicated, "Physical Abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. Mental Abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation ... Willful is ... means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. ... Forms of abuse can be as follows: ... 2. Resident to Resident Abuse of Any type "1. The following actions to prevent abuse, mistreatment, ... will include: 4. The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. D. Identification of possible incidents or allegations which need investigations: 3. If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation. 5. When an abuse is identified, the appropriate steps to protect residents from additional abuse will be implemented immediately, which will include: i. Conducting a thorough investigation of the alleged abuse ii. Taking steps to prevent further potential abuse iii. Take appropriate action that is reflected in the revise the care plan that addressed the resident's current medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse E. Investigation of incidents and allegations: 1. Initiate an investigation within 24 hours of an allegation of abuse that focuses on: i. Whether abuse or neglect occurred and to what extent; ii. Clinical examination for signs of injuries, if indicated; iii. Causative factors; and, iv. Interventions to prevent further injury." A review of the facility's Inservice (Education/training) titled, "Abuse and Neglect" lesson plan, dated January 19, 2023, included 12 types of abuse and Mandated Reporter, and that LVN 3 and LVN 4 attended the inservice. The lesson plan included lecture, and handouts of the facility policy entitled, "Abuse and Neglect Prohibition Policy" The course objectives were as follows: "At the conclusion of the presentation, the participants will be able to: 1. Define what Abuse is and how it is preventable 2. Verbalize the and provide example of the 12 types of Abuse 3. Identify who Abuse Prevention Coordinator is 4. Identify Mandated Reports" The facility failed to protect the resident's right to be free from physical abuse for Resident 3 in accordance with the facility's policy and procedures, dated June 2022, by failing to: 1. Ensure Resident 4 did not push Resident 3 on April 29, 2023. 2. Implement safety measures to protect Resident 3 from potential further physical abuse from Resident 4 by not sharing or remain in the same room after the incident on April 29, 2023. These deficient practices resulted in Resident 4 subjecting Resident 3 to physical abuse and mental abuse. Resident 3 fell to the ground, hit her head on the floor, and bled from the mouth after she was pushed by Resident 4. Resident 3 was visibly anxious and stated she feared for her life and could die if Resident 4 pushed her again. The above violations had direct or immediate relationship to the health, safety, or security of Resident 3.