Other·May 22, 2024

F600 §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; 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. 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 4/12/2024, an unannounced visit was made to the facility to conduct the facility reported incident regarding abuse. The facility failed to protect the resident’s right to be free from mental and physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for Resident 4 and Resident 2 when: -On 4/5/2024, Resident 5 threw urine from his urinal on to Resident 4 (the roommate) and both residents were engaged in a verbal altercation. - On 4/5/2024, Resident 5 did not receive a psychiatric evaluation, per the Physician’s Order and the care plan. -On 4/7/2024, after Resident 5 was moved to a different room, Resident 5 poured urine from his urinal onto the side of his bed, which splashed onto Resident 2 (the new roommate) and both residents were engaged in a verbal altercation. As a result, Resident 2 and Resident 4 being subjected to mental and physical abuse and psychosocial harm by Resident 5, while under the care of the facility. Resident 2 reported feelings of anxiety and feeling more depressed, and Resident 4 reported increased feelings of depression. a. A review of Resident 5’s Admission Record indicated the facility initially admitted the resident on 9/28/2023, with diagnoses including hemiplegia (one-sided muscle paralysis or weakness), hemiparesis (weakness or the inability to move on one side of the body), anxiety disorder, and major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). A review of Resident 5’s History and Physical, dated 10/26/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/9/2024, indicated the resident’s cognitive skills (ability to understand and make decisions) were intact and the resident was dependent on two or more-person assistance for showering, dressing, personal hygiene, and rolling left to right in bed. According to a review of the Change in Condition Evaluation (COC), dated 4/5/2024, timed at 1:23 P.M., Resident 5 was found yelling, cursing, and throwing things at his roommate (Resident 4). A review of Resident 5's Social Services Note, dated 4/5/2024 at 6:04 P.M., indicated Resident 4 and Resident 5 threw ice, water, and urinals at each other. The note indicated housekeeping had to clean the room and bedsheets of both residents. The Social Service note indicated both residents were placed on 1:1 supervision until a room change occurred and the Administrator spoke to both residents. A review of Resident 5’s Care Plan, initiated on 4/5/2024, indicated the resident had an altercation with a resident and the goal indicated to minimize emotional distress daily. The care plan interventions included to have a psychiatric consult, monitor, document and report sign of emotional distress every shift, anticipate care needs and provide them before the resident became overly stressed, and when resident becomes agitated to intervene before agitation escalates. A review of Resident 5’s Order Summary Report, dated 4/12/2024, indicated there was a physician’s order to transfer Resident 5 to GAGH 1 on 4/8/2024 related to verbal aggression towards a resident. A review of Resident 4’s Admission Record indicated the facility initially admitted Resident 4 on 9/18/2021 with a readmission date of 12/17/2021. Resident 4’s diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), chronic pain syndrome (a long lasting pain that persist beyond the usual recovery period), anxiety disorder (persistent and excessive worry that interferes with daily activities), major depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and insomnia (a condition when a person is not sleeping enough or having trouble falling or staying asleep). A review of Resident 4’s History and Physical, dated 9/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 4's MDS, dated 3/16/2024, indicated the resident’s cognitive skills were intact and needed supervision for showering, dressing, oral and toileting hygiene, eating, and walking 10 feet. The MDS indicated Resident 4 was feeling down, depressed, or hopeless. According to a review of Resident 4’s Medication Administration Record (MAR) from 4/1/2024 to 4/10/2024, the resident was on monitoring for episodes of anxiety manifested by an inability to relax and on monitoring for major depression manifested by verbalization of feeling hopeless. A review of Resident 4's Change in Condition Evaluation (COC), dated 4/5/2024, timed at 1:33 P.M., indicated the resident had behavioral changes manifested by verbal aggression and was found yelling, cursing, and throwing things at his roommate (Resident 5). A review of Resident 4’s Psychiatric Consultation, dated 4/9/2024, indicated that Resident 4 has a history of anxiety, depression, and insomnia. It also indicated that Resident 4 was seen regarding a recent altercation with another resident and no changes to his medication were made. On 4/12/2024 at 9:31 A.M. during an interview, Resident 4 stated that a few days ago around lunch time his roommate, Resident 5, splashed him and his bed with urine. Resident 4 stated that Resident 5 was yelling "F-words" and threatening him. Resident 4 further stated that this incident increased his anxiety, and for four days he was not able to perform his usual activities like walking, reading books and watching movies. During an interview, on 4/12/2024 at 12:15 P.M., Certified Nursing Assistant 2 (CNA 2) stated that on 4/5/2024 Resident 5 refused his diaper change at 7:45 AM and a few more times during that morning. CNA 2 stated that when she came back during lunch time with a lunch tray, Resident 5 asked her to change his diaper to which she responded that she would do it after lunch. Resident 5 then got upset and threw his lunch tray against the door. CNA 2 stated that Resident 5 and his roommate (Resident 4) started yelling, cursing, and throwing things at each other. b. A review of Resident 2’s Admission Record indicated the facility re-admitted the resident on 12/13/2021, with diagnoses including hemiplegia (one-sided muscle paralysis or weakness), hemiparesis, major depressive disorder, and insomnia (a condition when a person is not sleeping enough or having trouble falling or staying asleep). A review of Resident 2’s History and Physical, dated 11/26/2023, indicated the resident had fluctuating capacity to understand and make decisions. According to a review of Resident 2's MDS dated 3/13/2024, the resident had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks) and was dependent on two or more-person assistance for showering, dressing, personal hygiene, eating and rolling left to right in bed. A review of Resident 2’s Change in Condition Evaluation (COC) dated 4/8/2024 indicated that on 4/7/2024 (two days after the first incident on 4/5/2024) Resident 5 threw a urinal bottle filled with urine at Resident 2 and that Resident 2 then threw a bottle with water at Resident 5 in retaliation. Resident 2 was visibly soiled in urine and required cleaning after incident. A review of Resident 2’s Care Plan initiated on 4/8/2024, indicated that the resident was at risk for emotional distress due to an altercation with another resident (Resident 5). On 4/12/2024 at 9:07 A.M. during an interview, Resident 2 stated that on 4/7/2024 around 11:30 P.M., he asked Resident 5 to lower the volume of his cell phone because it was too loud. Resident 2 stated that Resident 5 did not want to lower the volume on his cell phone and instead he opened his urinal and threw urine on the edge of his bed which splashed onto Resident 2. When asked how the incident made him feel, Resident 2 stated he felt more depressed. On 4/12/2024 at 1:02 P.M. during an interview, the Director of Nursing (DON) stated that Resident 5 was involved in an emotional and verbal altercation with Resident 2 on 4/5/2024 and with Resident 4 on 4/7/2024 and it should not have occurred according to the Abuse policy. On 4/12/2024 at 2:15 P.M. during a phone interview, Licensed Vocational Nurse 3 (LVN 3) stated that on 4/5/2024, she reported altercation between Resident 5 and Resident 4 to Resident 5’s physician and received an order to transfer Resident 5 to the GAGH for a psychiatric evaluation. LVN 3 stated she did not follow up on the physician’s order to make sure that the transfer was arranged as soon as possible, as a result Resident 5 was transferred to a GAGH after the second altercation on 4/8/2024. LVN 3 stated that it was her mistake not to follow the physician’s order for Resident 5 on 4/5/2024. During an interview on 4/26/2024 at 9:48 A.M., the DON stated the Physician’s Order for Resident 5 to be transferred for a psychiatric evaluation was received on 4/5/2024 (after the first altercation). The DON stated Resident 5 was transferred to a General Acute Care Hospital (GACH) on 4/8/2024 after second altercation but did not go for the psychiatric evaluation, per the physician’s order. The DON stated that she could not explain why the nursing staff did not follow the physician’s order to transfer Resident 5 for a psychiatric evaluation on 4/5/2024. A review of the facility’s Policy and Procedure (P&P) titled, "Abuse Prevention Program," revised December 2016 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. The facility failed to protect the resident’s right to be free from mental and physical abuse for Resident 4 and Resident 2 when: -On 4/5/2024, Resident 5 threw urine from his urinal on to Resident 4 (the roommate) and both residents were engaged in a verbal altercation. - On 4/5/2024, Resident 5 did not receive a psychiatric evaluation, per the Physician’s Order and the care plan. -On 4/7/2024, after Resident 5 was moved to a different room, Resident 5 poured urine from his urinal onto the side of his bed, which splashed onto Resident 2 (the new roommate) and both residents were engaged in a verbal altercation. As a result, Resident 2 and Resident 4 being subjected to mental and physical abuse and psychosocial harm by Resident 5, while under the care of the facility. Resident 2 reported feelings of anxiety and feeling more depressed, and Resident 4 reported increased feelings of depression. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 2 and Resident 4.