Health inspection·November 7, 2024

California Code of Regulations, Title 22, Section 72315(b) § 72315. Nursing Service - Patient Care. (b)Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Code of Federal Regulations, Title 42 Section §483.12 Freedom from Abuse, Neglect, and Exploitation The patient has the right to be free from abuse, neglect, misappropriation of patient 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 patient’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; An unannounced visit was conducted by California Department of Public Health (CDPH) on 9/26/2024, to investigate a complaint regarding an allegation of patient-to-patient abuse. The facility failed to prevent verbal abuse (using words to name call, bully, demean, frighten, intimidate, or control another person) when Patient 1 expressed verbal aggression towards Patient 2 on 9/12/2024. This deficient practice violated Patient 2's right to be free from abuse and can cause emotional trauma to Patient 2. A review of Patient 1's Admission Record, indicated Patient 1, a 41 years old male was admitted to the facility on 9/4/2024, with diagnoses of restlessness and agitation, bipolar disorder (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]), and recurrent major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Patient 1's Minimum Data Set (MDS, a federally mandated patient assessment and tool), dated 9/13/2024, indicated Patient 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were intact. The MDS indicated Patient 1 had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) which placed others at significant risk for physical injury. A review of Patient 1's General Acute Care Hospital (GACH, dated 9/3/2024, the record indicated based on Patient 1's assessment, Patient 1 had seizure disorder (burst of uncontrolled electrical activity between brain cells that can cause the body to shake uncontrollably), bipolar disorder, depression, and hepatic encephalopathy (a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction after exclusion of brain disease). A review of Patient 1's Nurses Notes, dated 9/8/2024, the record indicated Patient 1 expressed he wanting to be transferred out to a different facility because he was asked to lower down his television (TV) volume by Patient 2 who had wanted to go to bed. There was no documented evidence that this has been addressed and/ or any follow up notes regarding the incident. A review of Patient 1's Social Services Notes dated 9/10/2024 entered at 5:40 PM, indicated will observe for mood and behavior (no specific behavior indicated) and will refer as indicated. A review of Patient 1's Care Plan, dated 9/12/2024, the care plan indicated Patient 1 had verbal aggression initiated towards other patient (Patient 2) using "F" words and other words of profanity. A review of Patient 1's Care Plans dated from 9/4/2024 to 9/12/2024, did not indicated documented evidence a care plan was developed that addressed Patient 1's restlessness and agitation. A review of Patient 1's Change in Condition Evaluation (COC, tool used by health care professionals when communicating about critical changes in a patient's status), dated 9/12/2024, indicated Patient 1 was noted to be agitated and verbally aggressive towards roommate, making threats towards Patient 2. A review of Patient 1's Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the patient), dated 9/13/2024, indicated late evening (on 9/12/2024), Patient 1 had the TV on at a high volume. Patient 1 responded with threatening language, stating, "I will f*** you up (addressing to Patient 2)." A review of Patient 1's Electronic Medication Administration Record (EMAR, a medical record used by healthcare providers to document the administration of a medication) and Treatment Administration Record (TAR, a medical record used by healthcare providers to document the administration of a treatment) for the month of September 2024, did not indicated documented evidence facility staff were monitoring Patient 1's restlessness, agitation and/ or irritability done for the month of September. A review of Patient 2's Admission Record, indicated Patient 2, a 63 years old male was initially admitted to the facility on 5/12/2023 and readmitted on 2/14/2024, with diagnoses of end stage renal disease (advanced stage kidney failure), dependence on renal dialysis(a lifesaving treatment for patients with kidney failure or end stage renal disease, and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel). A review of Patient 2's MDS, dated 8/21/2024, the record indicated Patient 2's cognitive skills for daily decision making were intact. The MDS indicated Patient 2 required partial/moderate assistance (helper does less than half the effort) for sit to lying, lying to sitting on side of bed, sit to stand, and walking ten feet. A review of Patient 2's COC, dated 9/12/2024, the record indicated Patient 2 received verbal threats from roommate (Patient 1) while Patient 2 was resting in bed. A review of Patient 2's care plan, dated 9/13/2024, the care plan indicated Patient 2 was at risk for emotional distress due to verbal aggression received. The care plan interventions for staff were to monitor for any sign or symptoms of emotional distress, psychiatric evaluation and treatment as needed, and 72-hour monitoring for any further change in condition. A review of Patient 2's Social Services Note, dated 9/13/2024, indicated Patient 2 stated, "I do not know why he (Patient 1) got so upset I just asked him to lower the volume on the TV." A review of the facility’s Final Investigation Report dated 9/16/2024, indicated Patient 1 raised his voice and used inappropriate language due to a concern about the loud volume of the television. The final investigation report also indicated the situation escalated when Patient 2 was disturbed by the noise, pushed the privacy curtain and began using inappropriate language. During an interview on 9/26/2024 at 3:06 PM with Patient 1 in Patient 1's room, Patient 1 stated, "Just did not like my roommate (Patient 2)." During a concurrent observation and interview on 9/26/2024 at 3:09 PM in the patio with Patient 2, Patient 2 stated every night Patient 1 talked too much, turned on the lights, and turned on the TV. Patient 2 stated he was not able to sleep because of the things Patient 1 did. Patient 2 stated on 9/12/2024, he requested Patient 1 to lower down the TV volume. Patient 2 stated Patient 1 started cursing at him and said "F-U". Patient 2 stated while they were roommates he did not want to go inside of his room and stayed outside in the patio to avoid Patient 1. During an interview on 9/26/2024 at 3:32 PM with Certified Nursing Assistant (CNA 1), CNA 1 stated Patients 1 and 2 were roommates for about a month and CNA 1 witnessed Patient 1 being verbally abusive against Patient 2 on 9/12/2024. CNA 1 stated she heard Patient 1 was saying "F-U" to Patient 2. CNA 1 stated Patient 2 was quiet during the incident and told CNA 1 he did not want any problems. During an interview on 9/26/2024 at 4:08 PM with the Activities Director (AD), the AD stated Patient 1 and Patient 2's incident on 9/12/2024 was because of the TV. AD stated Patient 1's TV was loud, and Patient 2 wanted to sleep and asked Patient 1 to please lower the TV volume. AD stated that when the nurses heard yelling on 9/12/2024, they came into Patient 1 and 2’s room. During an interview on 9/26/2024 at 5:16 PM with the Director of Nursing (DON), the DON stated the incident between Patient 1 and Patient 2 on 9/12/2024 was verbal abuse. The DON stated Patient 1 was admitted at the facility with diagnoses of restlessness, agitation, bipolar, and depressive disorder. During the same concurrent interview with the DON on 9/26/2024 at 5:16 PM, Patient 1's EMAR and TAR for the month of September 2024 was reviewed. The DON stated there were no documented evidence that Patient 1's behavior of restlessness, agitation and/ or irritability was monitored and documented, and staff should had monitored Patient 1's behavior to ensure we are able to address, intervene and avoid consequence of the Patient 1's behavior such as placing self and other patients at risk of verbal abuse. A review of the facility's policy and procedure titled, "Abuse Prevention and Prohibition Program," revised 8/1/2023, the record indicated each patient has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. For abuse prevention, staff are instructed to report any signs of stress from family and other individuals involved with the patient that may lead to abuse and intervene as appropriate. The facility failed to prevent verbal abuse (using words to name call, bully, demean, frighten, intimidate, or control another person) when Patient 1 expressed verbal aggression towards Patient 2 on 9/12/2024. This deficient practice violated Patient 2's right to be free from abuse and can cause emotional trauma to Patient 2. This violation had a direct or immediate relationship to the health, safety, or security of Patient 2 and other patients in the facility.