Health inspection·August 21, 2024

§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, or involuntary seclusion. 42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 22 CCR § 72311. Nursing Service - General. (a)Nursing service shall include, but not be limited to, the following (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 7/10/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an investigation for a facility reported incident regarding resident-to-resident abuse. The facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) on 6/26/2024 when Resident 2, who had a history of behavioral aggressiveness with outburst of anger, hit Resident 1 on the nose causing pain and redness to the nose. Resident 1 yelled and screamed, "Get away from me," and was transferred to the General Acute Care Hospital (GACH) for evaluation, he continued to verbalize feelings of depression and the psychiatrist increased the resident's dose of Luvox (fluvoxamine - an antidepressant medication used to treat unwanted repeated thoughts, obsessive compulsive disorders). Resident 1 was subjected to abuse and psychosocial (mental health) harm by Resident 2, while under the care of the facility. A review of Resident 2's admission record indicated the facility admitted the resident on 1/19/2024 with diagnoses including Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), psychosis (a mental disorder, collection of symptoms that affect the mind, where there has been some loss of contact with reality) and anxiety disorder. A review of Resident 2's Behavior Problem Care Plan, initiated 3/7/2024, indicated the resident had psychosis manifested by sudden outburst of anger. The goal was for Resident 2 to utilize acceptable methods of communicating needs and the interventions included to assist the resident in developing more appropriate methods of coping, interacting, and for caregivers to provide opportunity for positive interaction or attention. A review of Resident 2's Change in Condition (COC) form, dated 3/14/2024, indicated Resident 2 had an episode of physical aggression towards staff. Resident 2 hit the staff member on the chest. A review of the Activities, Cognitive Stimulation and Social Interaction care plan, developed 3/14/2024, indicated Resident 2 was dependent upon staff for these activities. The care plan interventions indicated all staff were to converse with Resident 2 while providing care and Resident 2 needed one to one bedside / in-room visits and activities if unable to attend out of room events. According to a review of Resident 2's History and Physical (H&P), dated 4/19/2024, the resident was recently discharged from the hospital due to confusion and agitation and was transferred to the hospital due to 5150 danger to self (the number of the section of the Welfare and Institutions Code, 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, to himself or herself, or gravely disabled). The H&P indicated the resident was currently diagnosed with major depression (a common and serious medical illness severe low mood, sadness and despair), psychotic features (collection of symptoms that affect the mind, where there has been some loss of contact with reality) and was being followed by psychiatry (a medical practitioner specializing in the diagnosis and treatment of mental illness). The H&P further indicated Resident 2 lacked capacity to make medical decisions. A review of Resident 2's Minimum Data Set (MDS, an assessment and care planning tool) dated 4/27/2024, indicated the resident's cognitive skills of daily decision were intact. The MDS indicated Resident 2 did not have physical or verbal behavioral symptoms directed towards others, which was a discrepancy compared to the Behavior Problem Care Plan, initiated 3/7/2024 and the COC dated 3/14/2024. A review of Resident 2's Nursing Home Visit note, dated 5/6/2024, indicated the resident was seen for a psychiatric consultation (a medical practitioner specializing in the diagnosis and treatment of mental illness) at the request of the primary physician to assess the resident's behaviors and to review any psychotropic medications (a group of drugs that doctors may prescribe to treat a variety of brain conditions). The note indicated Resident 2 was having sudden outbursts of anger, inability to sleep, and episodes of aggressive behavior towards staff. A review of Resident 2's COC form, dated 5/14/2024 at 1:30 AM, indicated Resident 2 was noted grabbing and spitting on staff members. Resident 2's behavior care plan was not updated to reflect the resident's behavior of grabbing and spitting at staff. According to a review of Resident 2's Nursing Home Visit note, dated 6/6/2024, Resident 2 continued to have sudden outbursts of anger. The note indicated the recommendation for a decrease in the resident's psychotropic medication dose was contraindicated because the benefits outweighed the risks for the resident and a reduction was likely to impair the resident's function and /or cause instability. A review of Resident 2's COC form, dated 6/26/2024 at 6:15 PM, indicated Resident 2 had physical aggression towards a roommate (Resident 1). The form indicated Resident 2 hit Resident 1's face, as Resident 2 was angry due to the roommate being very slow and Resident 2 needed to go to the restroom right away. The COC form indicated the psychiatrist ordered Resident 2 to transfer out of the facility on a 5150. A review of the Physician's Orders, dated 6/26/2024 (after the altercation), indicated the following: - monitor Resident 2 for 72 hours due to physical aggression - transfer Resident 2 on 5150 (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 disabled) due to physical aggression towards another resident - place Resident 2 on one-to-one observation (used to reduce the risk and incidence of harm to the resident). A review of the facility Nurses Notes dated 6/26/2024 at 9:19 PM indicated police arrived at facility and took a statement from Resident 2. The nurses notes indicated the care plan for Resident 1 was "ongoing, no further concerns as of present." There was no indication Resident 2's Behavior Problem Care Plan was updated since 3/7/2024 to include monitoring of Resident 2 or frequent observation. A review of the facility Nurses Notes dated 6/27/2024 at 7:02 AM indicated Resident 2 was placed on 1:1 monitoring, frequent visual checks provided, and plan of care was ongoing. There was no indication Resident 2's Behavior Problem Care Plan was updated since 3/7/2024 to include monitoring of Resident 2 or frequent observation. A review of Resident 1's Admission Record indicated the facility admitted the resident on 5/31/2024 with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and depression. According to a review of Resident 1's History and Physical, dated 6/1/2024, the resident had the capacity to understand and make decisions. A review of Resident 1's MDS dated 6/13/2024, indicated the resident's cognitive skills of daily decision were intact. The MDS indicated Resident 1 had little interest or pleasure in doing things and Resident 1 was feeling down, depressed or hopeless. The MDS also indicated the resident required partial to substantial assistance with oral hygiene, toileting hygiene, showering/bathing, and dressing. A review of Resident 1's Resident Grievance/Complaint Investigation Report dated 6/24/2024 (two days before the altercation) indicated Resident 1 reported not getting along with his roommate (Resident 2). The report indicated Resident 1 and his roommate were offered a room change and both refused. A review of Resident 1's COC form, dated 6/26/2024 at 6:15 PM, indicated Resident 1 received physical aggression, the resident's nose was red, and staff applied an ice pack. The COC indicated the physician ordered Resident 1 to receive an x-ray. A review of the Physician's Orders, dated 6/26/2024, indicated to transfer Resident 1 to a general acute care hospital (GACH) for further evaluation of nasal pain and redness, Resident 1 was to receive a stat (immediate) x-ray of the face due to nasal pain and redness, and was to have a psychiatrist and psychologist consultation. According to a review of Resident 1's Telemedicine Visit note, dated 6/27/2024, the resident was recently involved in a physical altercation with another resident (Resident 2), in which Resident 1 was the victim. The note indicated Resident 1 continued to verbalize feelings of depression and the psychiatrist increased the resident's dose of Luvox (fluvoxamine - a medication used to treat unwanted repeated thoughts) from 50 mg to 100 mg. During an interview on 7/10/2024 at 9:20 AM, Resident 1 stated while sitting in a wheelchair in their shared room (on 6/26/2024), Resident 2 walked past. Resident 1 stated Resident 2 then turned back around and hit Resident 1 in the face three times. During a phone interview on 7/10/2024 at 10:03 AM, Certified Nursing Assistant (CNA) 1 stated she heard Resident 2 screaming and yelling at Resident 1 on 6/26/2024. Resident 1 stated, "Get away from me," to Resident 2. CNA 1 stated then she observed Resident 2 hit Resident 1 in the face twice. CNA 1 stated she then went to inform the charge nurse. CNA 1 stated Resident 2 tended to be 'grumpy'. During an interview on 7/10/2024 at 10:24 AM, Licensed Vocational Nurse (LVN) 1 stated about two weeks ago (on 6/26/2024), while administering medications, RN Supervisor (RNS) 2 stated Resident 1 and Resident 2 had a physical altercation. LVN 1 stated upon assessing Resident 1, Resident 1 had a small area of redness on the nose. LVN 1 stated Resident 1 stated it was painful but refused pain medication. LVN 1 further stated Resident 2 was placed on one-to-one observation. LVN 1 stated Resident 2 had a history of behavioral aggressiveness. During an interview on 7/10/2024 at 10:49 AM, RNS 2 stated that on 6/26/2024 around 6 PM, RNS 2 heard a loud noise, and Resident 1 reported, " I was too slow to move out of his way, I think he became impatient, so he hit me twice." RNS 2 stated Resident 2 had a red area on the nose and law enforcement was notified. RNS 2 stated law enforcement determined Resident 2 did not qualify for 5150 transfer and Resident 1 was moved to a different room. RNS 2 further stated Resident 2 had a sudden outburst of anger toward staff in the past and if you did not give Resident 2 attention, he would become angry. On 7/10/2024 at 12:07 PM, during an interview, RNS 1 stated we have to remind Resident 2 to use his call light instead of screaming. During a concurrent review of Resident 2's COC Evaluation, dated 5/14/2024, where Resident 2 was noted to spit on staff, RNS 1 stated the care plan for this incident of Resident 2 being physically aggressive with staff was initiated late on 6/26/2024 (over one month later from the COC evaluation). RNS 1 further stated when Resident 2 was readmitted from the GACH on 7/3/2024 (after the altercation with Resident 1), the resident's dose of Seroquel (an antipsychotic medication that treats several kinds of mental health conditions) was increased from 25 milligrams (mg) to 50 mg. During a concurrent interview and record review on 7/10/2024 at 1:55 PM, Resident 1's Resident Grievance / Complaint Investigation Report, dated 6/24/2024, was reviewed. The Social Services Director (SSD) stated Resident 1 made a grievance against Resident 2 prior to the physical altercation (on 6/24/2024). The SSD stated Resident 1's grievance against Resident 2 was regarding Resident 2's TV being too loud and Resident 2's extended time in the restroom. The SSD stated when speaking to Resident 2 regarding Resident 1's complaint, Resident 2 refused to move and stated they would work the situation out. During an interview on 7/10/2024 at 4:09 PM, the Administrator (ADM) stated she was in the building when the altercation between Resident 1 and Resident 2 occurred. The ADM stated she completed an investigation into the incident, and it was determined Resident 2 hit Resident 1. A review of the facility's policy and procedure (P&P) titled, "Abuse Prevention and Prohibition Program," dated 10/1/2023, indicated the residents have the right to be free from abuse and neglect, or mistreatment. The policy indicated the facility was committed to protecting residents from abuse by anyone including staff, other residents, visitors, and others. A review of the facility's P&P titled, "Resident - Resident Altercations," dated 10/1/2023, indicated the facility acts promptly and conscientiously to prevent and address altercations between residents. The policy indicated the facility staff monitors residents for aggressive or inappropriate behavior toward other residents, separates the residents and institute measures to calm the situation. The facility failed to protect the resident's right to be free from physical abuse on 6/26/2024 Resident 2 hit Resident 1 on the nose causing pain and redness to the nose. Resident 1 was subjected to abuse and psychosocial harm by Resident 2, while under the care of the facility. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.