Other·April 10, 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; 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 2/9/2024, 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 and ensure Resident 1, who had diagnoses including dementia (loss of memory, thinking and reasoning) and anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities), was free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) from Resident 2. Resident 2, who was known to be aggressive, combative, would refuse her medications, had diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning) did not receive monitoring, per the resident care plan. The facility failed to: 1.Implement Resident 2's Schizophrenia care plan interventions, dated 1/25/2024, to monitor the resident for signs of impeding (about to happen) violence such as increasing activities, clenching fists (to press fingers tightly against the inside part of the hand, when angry), teeth and to keep the resident away from the proximity (closeness) of others if above symptoms were exhibited. 2. Notify Resident 2's physician to inform them Resident 2 refused her medications, including her psychotropic medications on three different occasions. 3. Monitor Resident 2 through visual checks every two hours, on 1/28/2024. 4. Implement the facility's policy and procedure titled, "Abuse Prevention Program," revised December 2016, to protect residents from abuse by anyone including, other residents. As a result, on 1/28/2024, Resident 1, an 83 year old female, was subjected to physical abuse by Resident 2, while under the care of the facility. Resident 2 hit Resident 1's face with an open hand. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1's moderately impaired cognition (ability of think and make decisions), an individual subjected to physical abuse can have lifetime physical pain and or psychological (mental or emotional) effects including feelings of embarrassment and humiliation. a. A review of Resident 2's Admission Record indicated the facility admitted the resident on 1/23/2024, with diagnoses including schizophrenia, major depressive disorder (a mood disorder with feelings of sadness, loss, anger, or frustration), and anxiety disorder. A review of the Physician's History and Physical (H&P) dated 1/24/2024, indicated Resident 2 was not competent (having capacity) to understand her medical condition. A review of the Physician's Orders dated 1/24/2024, indicated Resident 2 was to receive Quetiapine Fumarate (medication that treats several kinds of mental health conditions including schizophrenia) 100 milligrams (mg) two times a day for schizophrenia, Lorazepam 1 mg two times a day for anxiety and Clozapine (medication used to treat schizophrenia) 100 mg two tablets at bedtime. According to a review of Resident 2's Care Plan for schizophrenia initiated on 1/25/2024, the goal was for the resident to not have injuries to self or others during outbursts. The care plan interventions indicated to monitor the resident for signs of impeding (about to happen) violence such as increasing activities, clenching fists (to press fingers tightly against the inside part of the hand, when angry), teeth and to keep the resident away from the proximity (closeness) of others if above symptoms were exhibited. A review of Resident 2's Medication Administration Records (MAR) indicated Resident 2 refused to take Clozapine on 1/25, 1/28, and 1/29/2024 at 9 PM. The MAR indicated that Resident 2 refused to take Lorazepam on 1/25, 1/26, and 1/28/2024 at 9 AM. The MAR further indicated Resident 2 refused to take Quetiapine 100 mg on 1/25/2024 at 5 PM, and on 1/26/2024 at 9 AM. A review of Resident 2's Change of Condition (COC) - Situation-Background-Assessment and Recommendation form (SBAR - a written communication tool that helps provide important information) dated 1/28/2024 at 4:33 PM, (five days after admission) indicated Resident 2 had an altercation with Resident 1 and hit Resident 1 on the face with an open hand. The SBAR form indicated Resident 2 had behavioral issues and was not compliant with commands (orders) and her medications. A review of the Physician's Orders dated 1/30/2024 (after the altercation) indicated Resident 2 was to receive monitoring of the behaviors of schizophrenia manifested by aggressive behavior and anxiety. Further review of the Physician's Orders (after the altercation) indicated Resident 2 to receive monitoring of behaviors of schizophrenia manifested by outburst (sudden violent expression of strong feeling) towards others every shift. According to a review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 1/31/2024, Resident 2 had severely impaired cognition and required supervision with eating, toileting, oral, and personal hygiene. b. A review of Resident 1's Admission Record indicated the facility admitted the resident on 10/27/2023, with diagnoses including dementia (loss of memory, thinking and reasoning), schizoaffective disorder (a mental health condition with symptoms of schizophrenia and mood disorder) and anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). A review of the Physician's History and Physical (H&P) dated 10/28/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's MDS dated 11/2/2023, indicated Resident 1 had severely impaired cognition (never/rarely made decisions) and required moderate assistance with toileting, personal hygiene and upper and lower body dressing. According to a review of Resident 1's COC - SBAR dated 1/28/2024 at 5:49 PM, indicated Resident 1 was hit on her face by another resident (Resident 2) with an open hand. The SBAR indicated the only witness to this altercation was another resident (Resident 3). During an interview on 2/9/2024 at 9:10 AM, with Resident 1 inside the activity room, Resident 1 stated she did not recall being slapped on her face outside in the patio. A review of Resident 1's Care Plans on 2/9/2024 at 12 PM, indicated no care plan was initiated after Resident 1 was hit by Resident 2 on her face. c. A review of Resident 3's Admission Record indicated the facility admitted the resident on 12/13/2023, with diagnoses including schizophrenia, major depressive disorder, and anxiety disorder. A review of the Physician's History and Physical (H&P) dated 12/14/2023, indicated Resident 3 was competent to understand her medical condition. According to a review of the MDS dated 12/19/2023, Resident 3 had intact cognition (decisions consistent/reasonable) and required supervision with upper and lower body dressing, and toileting, oral, and personal hygiene. During an interview on 2/9/2024 at 9:23 AM, with Resident 3 inside his room, Resident 3 stated he witnessed the physical altercation between Resident 1 and Resident 2. Resident 3 stated, "On 1/28/2024, in the afternoon, I was outside in the patio. Resident 2 was laying on a bench covered with blankets. Resident 1 walked towards Resident 2 and tried to adjust her blankets. Out of nowhere, Resident 2 slapped Resident 1 on her face. Resident 1 did not fall or did not have any injuries." During an interview on 2/9/2024 at 10:02 AM, the Activity Assistant (AA) stated, "On 1/28/2024, Sunday, I was working in the facility from 10 AM-6:30 PM. I was inside the activity room when Resident 3 came to me and stated the lady got hit." I asked Resident 3 who hit who and she stated, "The black lady (Resident 2) hit the older lady (Resident 1)." The AA stated, "Resident 1 came inside the activity room and told me that she offered to help Resident 2 to carry her blankets and Resident 2 slapped her on the face." The AA stated, "I informed the Licensed Vocational Nurse (LVN 1) about the alleged abuse incident." On 2/9/2024 at 10:11 AM, during a telephone interview, LVN 1 stated, "Resident 2 was strange, she would put toothpaste all over her mouth. She would do some weird stuff; she would say non-logical stuff. She had psych issues." LVN 1 stated, "The AA reported to me about the altercation between Resident 1 and Resident 2 and I went to the activity room and both residents were there. I made sure they were not together. Resident 1 and Resident 2 were not able to give me clear reports of what happened. Resident 3 told me that Resident 2 slapped Resident 1's face." LVN 1 stated, "When I interviewed Resident 1, she did not say much about the incident, she was not able to tell me what had happened, she just mumbled." During an interview on 2/12/2024 at 11:40 AM, LVN 3 stated, "Resident 2 was aggressive towards other residents; she was pushing other residents. Resident 2 was going inside other residents' room. LVN 3 stated there were two binders including monitoring logs for all residents for every two hours. One binder was for Certified Nursing Assistants (CNA) to document and the other one was for LVNs to complete. During a concurrent record review and interview with LVN 3, the Active Residents, Every Two-Hour Visual Check logs were reviewed. LVN 3 stated, "This log has the residents' room numbers and not their names. We do not have time to complete this log every two hours for each resident." LVN 3 stated, "These binders were the only place staff documents the residents` visual checks." LVN 3 stated the visual check log for 1/28/2024, for all residents were missing from the binder. LVN 3 stated the potential outcome of not monitoring the resident frequently was injuries or accidents. During a concurrent interview and record review, on 2/12/2024 at 12:10 PM, with the facility's Director of Nursing (DON), Resident 2's MAR for January, the care plans and the nursing progress notes were reviewed. The DON stated, "Resident 2 was out of control, she was aggressive, combative, and would refuse her medications. The DON stated if a resident refused to take her medication on three different occasions, licensed staff were required to call the physicians and make them aware. The DON stated Resident 2 did refuse her medications, including her psychotropic medications on three different occasions. However, the required notification to the physician was not made. The DON stated the potential outcome of not taking psychotropic medication could be aggressive behavior and the potential outcome of not notifying the physician was the inability to take the appropriate steps as a result of the resident's refusal. The DON stated Resident 2's schizophrenia care plan was initiated on 1/25/2024 and was not revised after resident's physical altercation on 1/28/2024. The DON stated one of the interventions was to monitor for signs of impeding violence such as increasing activities, clenched fists, and teeth and to keep the resident away from others if symptoms were exhibited. The DON stated this intervention was not being implemented and documented anywhere in the resident`s medical record. The DON stated the only place that residents' visual monitoring was documented was the binder which included visual check logs. The DON confirmed the resident's visual check monitoring log was missing for 1/28/2024. The DON stated, "This is not an effective way of monitoring residents." The DON stated the potential outcome of not monitoring residents with psychological problems was accidents, injuries, and harm to other residents. During a concurrent interview and record review on 2/12/2024 at 12:30 PM, with the DON, Resident 1's care plans were reviewed. The DON stated staff did not initiate a person-centered care plan for Resident 1 after Resident 2 hit her face with an open hand on 1/28/2024. The DON stated licensed staff were required to initiate a person-centered care plan for each resident after a change of condition. The DON stated the potential outcome was inability to establish interventions to monitor the resident and deliver appropriate care. A review of the facility's policy and procedure titled, "Abuse Prevention Program," revised December 2016, indicated our residents have the right to be free from abuse, neglect and misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including but not necessarily limited to facility, staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. A review of the facility's policy and procedure titled, "Goals and Objectives, Care Plans," revised April 2017, indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives were defined as the desired outcome for a specific resident problem. When goals and objectives were not achieved, the resident's clinical record would be documented as to why the results were not achieved and what new goals and objectives have been established. Goals and objectives were reviewed and or revised where there has been a significant change in condition in the resident's condition. The facility failed to protect the resident's right and ensure Resident 1, who had diagnoses including dementia and anxiety disorder, was free from physical abuse from Resident 2. Resident 2, who was known to be aggressive, combative, would refuse her medications, had diagnoses including schizophrenia did not receive monitoring, per the resident care plan. The facility failed to: 1.Implement Resident 2's Schizophrenia care plan interventions, dated 1/25/2024, to monitor the resident for signs of impeding violence such as increasing activities, clenching fists, teeth and to keep the resident away from the proximity of others if above symptoms were exhibited. 2. Notify Resident 2's physician to inform them Resident 2 refused her medications, including her psychotropic medications on three different occasions. 3. Monitor Resident 2 through visual checks every two hours, on 1/28/2024. 4. Implement the facility's policy and procedure titled, "Abuse Prevention Program," revised December 2016, to protect residents from abuse by anyone including, other residents. As a result, on 1/28/2024, Resident 1 was subjected to physical abuse by Resident 2, while under the care of the facility. Resident 2 hit Resident 1's face with an open hand. Based on the reasonable person concept due to Resident 1's moderately impaired cognition, an individual subjected to physical abuse can have lifetime physical pain and or psychological effects including feelings of e