Health inspection·September 19, 2023

On 8/30/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about resident-to-resident abuse. The facility failed to implement its abuse prevention policy and procedures by failing to report to the State Agency (SA) the unusual occurrence of a resident-to-resident altercation (negative and aggressive physical, sexual, or verbal interactions between long-term care residents) for two of four residents (Residents 1 and 6). This deficient practice placed Residents 1 and 6 at risk for further resident-to-resident altercations and resulted in an altercation between Residents 1 and 2 on 8/20/2023. A review of Resident 1's admission record (facesheet) indicated Resident 1 was admitted to the facility on 7/27/2023 from a General Acute Care Hospital (GACH), with diagnoses that included major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and insomnia (unable to fall asleep or stay asleep). A review of Resident 1's history and physical (H&P) dated 7/28/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/30/2023, indicated Resident 1's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) is severely impaired. Resident 1 required one person physical assist with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 1's nursing progress notes dated 8/9/2023, completed by Licensed Vocational Nurse 1 (LVN 1), indicated Resident 1 forcefully took Resident 6's (roommate) eyeglasses, tried to break the glasses, and claimed the glasses were for Resident 1. Resident 1 left the room when Certified Nursing Attendant 1 (CNA 1) took the eyeglasses. The nursing progress notes indicated Resident 1's roommates were scared to be in the room with Resident 1. The nursing progress notes indicated that on 8/9/2023 at about 5:30 PM, Resident 1 threw her water pitcher containing water on Resident 6's feet. The nursing progress notes indicated LVN 1 showed the Director of Nursing 1 (DON 1) the glasses and told DON 1 about the incident with Resident 1. The nursing progress notes indicated the DON, "referred me [LVN 1] to social services, but I could not find anyone in the social services office." A review of Resident 1's change of condition (COC- a decline in health, mental, or psychosocial status) dated 8/9/2023, indicated Resident 1 was aggressive towards Resident 6 in two separate episodes. A review of Resident 1's care plan dated 8/10/2023, indicated Resident 1 had the potential to demonstrate abusive behaviors related to dementia, ineffective coping skills and poor impulse control. The goal included for Resident 1 to demonstrate effective coping mechanisms through the review date of 10/8/2023. The interventions included to assess the coping skills and support system, monitor and document observed behavior, and attempted inventions in behavior log for Resident 1. The intervention included a psychiatric consult (a comprehensive evaluation of the psychological, biological, medical and social causes of emotional distress) as indicated and when Resident 1 becomes agitated. A review of Resident 6's admission record indicated the facility initially admitted Resident 6 on 2/10/2023, and readmitted Resident 6 on 7/12/2023 from the GACH with diagnoses that included dementia, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and difficulty in walking. A review of Resident 6's H&P dated 7/13/2023, indicated Resident 6 had the capacity to understand and make decisions. A review of Resident 6's MDS dated 8/10/2023, indicated Resident 6's cognition was severely impaired. Resident 6 required set up assist with bed mobility, transfer, toilet use, personal hygiene and one personal physical assist with dressing. A review of Resident 6's nursing progress notes for the month of August 2023, did not indicate any altercation or incident between Resident 6 and Resident 1. During an interview with Resident 6 on 8/30/2023 at 2:45 PM, Resident 6 stated Resident 1 used to be her roommate. Resident 6 stated the facility moved Resident 1 to another room after an incident with Resident 1. Resident 6 stated Resident 1 came up to her near the bathroom and took her eye glasses and was not sure why Resident 1 did that. Resident 6 would not answer any further questions regarding the incident. During an interview with CNA 1 on 8/30/2023 at 2:20 PM, CNA 1 stated, "I heard [Resident 6] yelling and I went to check why she was yelling. I saw [Resident 1] push [Resident 6] back onto the bed [Resident 6's bed] . [Resident 1] then took [Resident 6's] eyeglasses. I tried to calm [Resident 1] down by talking calmly to her, but she would not calm down. [Resident 1] then folded [Resident 6's] glasses and gave them to me. Resident 1 finally calmed down and I informed the charge nurse of the incident." During an interview with LVN 1 on 8/31/2023 at 12:00 PM, LVN 1 stated CNA 1 informed LVN 1 on 8/9/2023 that Resident 1 took Resident 6's eyeglasses claiming that they belonged to Resident 1. LVN 1 stated Resident 1 tried to break the eye glasses and that Resident 1 threw a water pitcher at Resident 6's feet. LVN 1 stated, "I informed my DON 1 and the DON told to speak with social services, but social services were not in the facility at that time." LVN 1 stated she notified Resident 1's physician and Resident 1's responsible party. LVN 1 stated, "yes" that the incident between Resident 1 and Resident 6 was considered abuse. LVN 1 stated she did not report the incident between Resident 1 and Resident 6 to the SA. LVN 1 stated, "I only reported it [incident between Resident 1 and Resident 6] to the DON 1 and medical doctor (MD)." During an interview with Social Services Director 1 (SSD 1) on 8/31/2023 at 12:10 PM, SSD 1 stated that on 8/10/2023, she was informed of the incident between Residents 1 and 6 on 8/10/2023 morning. SSD 1 stated she reviewed the COC for resident 1 dated 8/9/2023. SSD 1 stated she followed up with Resident 1 on 8/10/2023 following the incident but was unsure if the incident was reported to the SA. During an interview and concurrent record review with DON 2 on 8/31/2023 at 2:30 PM, Resident 1's progress notes completed by LVN 1 were reviewed. DON 2 stated that he began working in the facility on 8/21/2023. DON 2 stated the incident between Resident 1 and Resident 6 that occurred on 8/9/2023 was considered as resident to resident abuse, and should have been reported to the SA, Ombudsman (advocate for residents residing in skilled nursing facility) and the local police department. DON 2 stated that he is unsure why the incident between Resident 1 and resident 6 was not reported to the proper authorities. During an interview and concurrent record review with the Administrator (ADM) on 8/31/2023 at 2:45 PM, Resident 1's nursing progress note completed by LVN 1 dated 8/9/2023 were reviewed. The ADM stated the incident between Resident 1 and Resident 6 would be considered as resident-to-resident altercation and should have been reported to the SA, Ombudsman and local police per the facility abuse policy. The ADM stated she was unaware the incident between Resident 1 and Resident 6 because she was not in the facility at that time. A review of the facility's policy and procedures titled "Abuse Prevention Program" revised 12/2016, indicated, "our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms." A review of the facility's policy and procedures titled "Abuse Investigation and Reporting" revised 7/2017, indicated, "all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknow source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported." The facility failed to implement its abuse prevention policy and procedures by failing to report to the SA the unusual occurrence of a resident-to-resident altercation for two of four residents (Residents 1 and 6). This deficient practice placed Residents 1 and 6 at risk for further resident-to-resident altercations and resulted in an altercation between Residents 1 and 2 on 8/20/2023. The above violations had a direct relationship to the health, safety, and security of all residents in the facility.