Health inspection·July 26, 2022

42 CFR §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. On 6/17/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about resident quality of care. The facility failed to ensure Resident 1 had the right to be free from abuse from Certified Nursing Assistant 1 (CNA 1) as per its policy on abuse. On 6/12/2022, at around 1:00 am, CNA 1 squeezed Resident 1's right wrist. As a result, Resident 1's right wrist was bruised (blood or bleeding under the skin due to trauma of any kind; typically, black, and blue at first, with color changes as healing progresses) and the resident feared CNA 1. A review of Resident 1's Admission Record (Face Sheet) indicated the facility initially admitted the resident on 10/1/2019 with the most recent readmission dated 3/13/2020. Resident 1's diagnoses included fracture (break) of the left tibia (shin bone), hemiplegia (paralysis [loss of the ability to move] of one side of the body), hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating and drinking), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 3/9/2022, indicated Resident 1 was able to communicate, understand, remember, and make decisions. Resident 1 required extensive assistance with bed mobility, transfers from / to bed, toilet use, and personal hygiene. Resident 1 was incontinent (unable to voluntarily control the retention of urine and feces in the body) of urine and bowel functions. A review of Resident 1's History and Physical (H&P) exam completed by the attending physician on 6/02/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's nursing Progress Notes, dated 6/12/2022 and timed at 8:37 am by the Treatment Nurse, indicated CNA 3 reported Resident 1 had discoloration on the right wrist. The Treatment Nurse described the resident's right wrist having red to purple skin discoloration and the pain level was four out of 10 (4/10 - a numerical pain assessment tool; zero indicating no pain and10 the wort possible pain). Resident 1 reported to the Treatment Nurse that on 6/11/2022 at around 11:00 pm, she called CNA 1 to change her incontinent brief. After CNA 1 changed the resident's brief, CNA 1 squeezed Resident 1's hand "so powerfully." Resident 1 stated she did not know why CNA 1 "did that, but she must have hated her (Resident 1)." Resident 1 did not report the incident during the night shift because she did not know who to call and was scared. A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation - communication technique between the health care team) dated 6/12/2022 timed at 9:00 am, indicated Resident 1 complained of new onset 4/10 pain level on her right wrist. The physician was notified and ordered X-ray of the right wrist and Tylenol (medication for pain) 325 milligrams (mg) two tablets by mouth every four hours PRN (as needed), and cold pack offered. Resident 1 refused the Tylenol. A review of Resident 1's Psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders) assessment, dated 6/16/2022, did not address the resident's allegation of abuse dated 6/12/2022. A review of Resident 1's IDT (Interdisciplinary Team - a team of professionals from different health care disciplines who provide care to the resident), dated 6/17/2022, did not include documentation about Resident 1's alleged abuse dated 6/12/2022. A review of the facility's undated 5-day Investigation Report conclusion indicated CNA 1 grabbed Resident 1's wrist when the resident was flailing (waving/swinging) her arms perhaps to try to calm the resident down and clean/change Resident 1. On 6/17/2022, at 9:35 am, during an observation of Resident 1 and concurrent interview, Resident 1's right wrist had a dark purple bruise which measured three inches in length by three inches in width. Resident 1 told the Evaluator the same account of the abuse from CNA 1 during the night shift (6/11/2022 11 pm to 6/12/2022 7 am) at round 1:00 am. Resident 1 stated CNA 1 removed and placed the wet incontinent brief on her lower abdomen and applied a clean incontinent brief. Resident 1 stated CNA 1 did not fasten the incontinent brief with attached adhesive tape. CNA 1 grabbed and squeezed Resident 1's right wrist when Resident 1 asked why she (CNA 1) did not clean her private area before applying a clean incontinent brief. Resident 1 stated she screamed in pain asked CNA 1 why she "was acting like this," but CNA 1 did not respond. Resident 1 stated she did not report the incident immediately after it happened because she felt scared and afraid on that entire night that CNA 1 would come back if she needed help. Resident 1 stated, she reported the incident to CNA 2 on 6/12/2022 at 7:00 am and the Treatment Nurse offered her pain medication and ice pack which she refused. Resident 1 said the X-ray result showed no broken bones. On 6/21/2022, at 5:55 pm, during a telephone interview, CNA 1 stated she was from a registry (staffing agency), denied abusing Resident 1, and stated she did not know about the resident's hand until the next day when the Treatment Nurse told her about it. A review of the facility's policy and procedures titled, "Abuse Prevention and Prohibition Program (APP Program)," revised date 6/1/2021, indicated: 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. 2. The Facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, friends, and visitors. 3. The Administrator is responsible for coordinating and implementing the Facility's APP Program, policies, procedures, and training programs. The facility failed to ensure Resident 1 had the right to be free from abuse CNA 1. On 6/12/2022, at around 1:00 am, CNA 1 squeezed Resident 1's right wrist. As a result, Resident 1's right wrist was bruised, and the resident feared CNA 1. The above violations had a direct relationship to the health, safety, and security of all residents in the facility.