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. 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 7/8/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the recertification survey. 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 6/23/2024 when Resident 206 had an aggressive behavior, was angry and upset. and splashed coffee onto another resident (Resident 35) and on the same day, later Resident 206 struck Resident 5 in the face with an open hand. The facility also failed to prevent Resident 206 from splashing coffee onto Resident 35 on 6/3/2024. As a result, Resident 5 and Resident 35 were subjected to abuse and psychosocial harm by Resident 206, while under the care of the facility. Resident 5 asked the police to take Resident 206 away. A review of Resident 206's Admission Record indicated the resident was admitted to the facility on 5/8/2024, with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Parkinson disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 206's History and Physical (H&P) dated 5/9/2024, indicated the resident was not competent to understand her medical condition. A review of Resident 206's Care Plan for the Alteration in Psychosocial Well-being related to schizophrenia and bipolar disease initiated on 5/9/2024, indicated Resident 206 had a history of self-harm. The care plan goal was for the resident to show gradual positive progress towards interacting with others for the next three months. The care plan interventions indicated to allow the resident to verbalize feelings, concerns, or fears, to identify issues causing stress to the resident, address issues of concerns, identify issues important to the resident and offer social services assistance if needed, and to encourage active involvement in activities for socialization and stimulation. A review of Resident 206's Care Plan for Bipolar disorder initiated on 5/11/2024, indicated the goal for the resident was to not have injuries to herself or others during outbursts for three months. The care plan interventions indicated to monitor the resident for signs of impeding violence such as increasing activities, clenching fists, teeth and to keep the resident away from proximity of others, if above symptoms were exhibited, to provide diversional activities to keep the resident occupied and to review medications and diagnoses for possible causes of behaviors and address issues of concerns. According to a review of Resident 206's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/14/2024, the resident's cognitive skills (ability to think, remember and make decisions) for daily decision making was intact, but had trouble concentrating on things such as reading the newspaper. The MDS indicated Resident 206 had trouble falling or staying asleep, was feeling tired or having little energy, and did not display any psychosis (symptoms that happen when a person was disconnected from reality) behavior. A review of Resident 206's Nursing Progress Note dated 6/2/2024 at 9:45 AM, indicated the resident was being monitored for aggressive behavior, was redirected at times during the shift, and was re-educated on appropriate behaviors in activity room and hallways. A review of Resident 206's Social Service Note dated 6/3/2024 at 1:54 PM, indicated the resident was being monitored for aggressive behavior, as the resident got angry and upset and splashed coffee onto another resident. The note indicated Resident 206's conservator (a person appointed by the court to make decisions about personal matters for a person who is not able to make his/her own decision, including decisions about medical care, food, clothing, where the person will live) and psychiatric doctor were made aware. This social service note was stricken by Social Services Director (SSD) on 6/24/2024 at 3:57 PM and was marked as incorrect documentation. what was done after this incident? c/p updated? A review of Resident 206's Change of Condition - SBAR Form (Situation-Background-Assessment and Recommendation - a written communication tool that helps provide important information) dated 6/23/2024 at 1:05 PM, indicated Resident 206 displayed aggressive behavior towards her roommate (Resident 5). According to a review of the Nursing Progress Note dated 6/23/2024 at 2:23 PM, Resident 206 assaulted another resident (Resident 5) at 2 PM, the Police Department arrived at the facility and arrested Resident 206 for assault. A review of Resident 5's Admission Record indicated the facility readmitted the resident on 1/10/2024, with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), 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 Resident 5's MDS dated 3/30/2024, indicated the resident's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). A review of Resident 5's History and Physical (H&P) dated 5/31/2024, indicated that the resident had the capacity to understand and make decisions. A review of Resident 5's Nursing Progress Notes dated 6/23/2024 at 2 PM, indicated the resident was struck three times with an open hand by her roommate. According to a review of Resident 5's Nursing Progress Notes dated 6/23/2024 at 2:25 PM, on 6/23/2024 at around 2 PM, Resident 5 was walking out of her room while Resident 206 was standing by at the front of the door. Resident 5 wanted to pass through the door and asked to be excused and Resident 206 did not respond. The note further indicated that Resident 206 hit Resident 5 for no reason. A review of Resident 35's Admission Record indicated the facility readmitted the resident on 5/15/2023, with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior). A review of Resident 35's MDS dated 3/30/2024, indicated the resident's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). A review of Resident 35's History and Physical (H&P) dated 5/9/2024, indicated the resident was not competent to understand her medical condition. During an interview on 7/10/2024 at 8:30AM, inside Resident 5's room, with Certified Nursing Assistant (CNA) 4, Resident 5 stated she never had any issues with any of her roommates. During a concurrent interview at 8:40 AM, Resident 5 asked CNA 4 "Why did Resident 206 hit me?" Resident 5 stated, "She just did not like me." CNA 4 stated, "On 6/23/2024, in the afternoon Resident 5 asked me for toothpaste and a brush. I went to the supply room at the end of the hallway. When I looked back, I saw Resident 5 was standing at her door and Resident 206 was standing in the hallway. I witnessed Resident 206 hit Resident 5 three times one on her head, one on her cheek and one on her neck. When the police came Resident 5 asked the police to take her (Resident 206) away." During an interview on 7/10/2024 at 10:45 AM, Licensed Vocational Nurse (LVN) 1 stated, "Resident 206 had behavioral issues," and was extremely frustrated because she did not receive her monthly money from her conservator. LVN 1 stated Resident 206 was Resident 5's roommate and on 6/23/2024, Resident 5 and Resident 206 were talking in the hallway next to their room, in a verbal altercatation. Then Resident 206 started hitting Resident 5 three times with an open hand. LVN 1 stated Resident 5 requested the police to come. Resident 5 kept saying she wanted to call the police. Resident 206 stated she was going to do it again. The police came and arrested Resident 206 for an assault. On 7/10/2024 at 11:26 AM, during an interview, the Social Services Director (SSD) stated Resident 206 was involved in another resident-to-resident altercation before 6/23/2024. The SSD stated Resident 206 threw coffee at another resident (Resident 35) but did not remember which resident. The SSD further stated, "On 6/2/2023, both residents were in the activity room. Resident 206 got upset and she threw coffee at the other resident (Resident 35). I made some notes in Resident 206's chart regarding her aggressive behavior on 6/2/2024, however, I deleted the notes because a lot had happened, and I wanted to add some more information. The SSD stated licensed staff did not develop a change of condition - SBAR for this incident for Resident 206. The SSD stated, "The other affected resident was not monitored for any emotional distress after the incident." During an interview on 7/10/2024 at 11:49 AM, CNA 5 stated, "I heard that Resident 206 threw coffee at another resident on 6/2/2024. In the morning huddle we were told to keep a close eye on Resident 206." During an interview on 7/10/2024 at 11:57 AM, LVN 3 stated, "Resident 206 was alert, ambulatory and a smoker. She had days that she was calm and days that she was mad. Resident 206 would throw coffee and food on the floor." During a telephone interview on 7/10/2024 at 12:41 PM, the Activity Assistant (AA) stated on Sunday 6/2/2024 at around 5 PM, Resident 206 threw coffee at Resident 35 inside the activity room. AA stated, "I asked her why she did it and she did not answer. We had to call a charge nurse to check Resident 35. Resident 35 was assessed, and he was fine." During an interview on 7/10/2024 at 1:02 PM, inside Resident 35's room, Resident 35 stated that Resident 206 threw coffee at him. Resident 35 stated he was sitting in activity room and Resident 206 threw coffee at him for no reason. He stated the coffee hit him at his chest, face and in his eyes. He stated the coffee was not hot and he did not get burned. Resident 35 stated, "I did not tell Resident 206 anything because she was a girl. I just let it go." On 7/10/2024 at 2 PM, during an interview, the facility's Director of Nursing (DON) stated Resident 5 did not sustain any injuries and she verbalized that she was feeling safe in the facility. Resident 206 was removed from the facility by the police. The DON stated, "I have a binder and there is documentation regarding Resident 206 throwing coffee at another resident on 6/2/2024. However, the incident was not documented as an allegation of abuse." The DON stated he was not sure what interventions were done for Resident 206 after the incident on 6/2/2024. During an interview on 7/10/2024 at 2:20PM, the facility's Administrator (ADM) stated that the incident on 6/2/2024, between Resident 206 and Resident 35 was not reported to CDPH, ombudsman, or the police department. The ADM stated this was a reportable incident. The ADM stated she was in charge of reporting the allegation of physical abuse between Resident 206 and Resident 5. The ADM stated, "The potential outcome of not reporting a resident-to-resident physical altercation is a delay in the investigation and delivery of necessary interventions to ensure resident safety. A review of the facility's documentation of its Leadership Staff dated from 10/2023 to 6/27/2024 indicated the facility had an Interim DON working at the time of this incident and an Interim Administrator was also working during this incident. The Interim Administrator last day was 6/3/2024, and the abuse was not reported or investigated. A review of the facility's policy and procedure titled, "Abuse, Neglect, Exploitation and Misappropriation Prevent Program," reviewed April 2024, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegation within timeframe required by federal requirements. Protect residents from further harm during investigation. Implement measures to address factors that may lead to abusive situations. A review of the facility's policy and procedure titled, "Abuse Prevention Program," reviewed 4/11/2024, indicated as a part of 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 individual. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse. Investigate and report any allegations of abuse within timeframes as required by federal requirements. The facility failed to protect the resident's right to be free from physical abuse on 6/23/2024 when Resident 206 had an aggressive behavior, was angry and upset. and splashed coffee onto another resident (Resident 35), and on the same day, later Resident 206 struck Resident 5 in the face with an open hand. The facility also failed to prevent Resident 206 from splashing coffee onto Resident 35 on 6/3/2024. As a result, Resident 5 and Resident 35 were subjected to abuse and psychosocial harm by Resident 206, while under the care of the facility. Resident 5 asked the police to take Resident 206 away. The above violation had direct or immediate relationship to the health, safety, or security of Resident 5 and 35.