Health inspection·November 26, 2024

§ 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. § 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. § 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. F600 §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 on 10/29/2024 at 8:40 AM to investigate a facility reported incident regarding a patient- to- patient physical abuse (intentional act causing injury or trauma to another person). The facility failed to protect Patient 1 from physical abuse by Patient 2. On 10/25/2024, Patient 2 hit Patient 1 with a cane. This deficient practice resulted in pain, redness and swelling to Patient 1’s left wrist, as well as anxiety (anticipation of future danger accompanied by a feeling of distress, sadness, hype-vigilance, and tension). A review of Patient 1’s Admission Record, the Admission Record indicated Patient 1 is a 41-year-old male who was admitted to the facility on 8/21/2024 with diagnosis of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) following a motor-vehicle accident. A review of Patient 1’s History and Physical (H&P- a term used to describe a physician’s examination of a Patient) dated 10/5/2024 indicated Patient 1 can understand and make own medical decisions and is bed bound (unable to move around independently, safely, or comfortably due to illness or injury). A review of Patient 1’s Minimum Data Set (MDS- a standardized Patient assessment and care screening tool) dated 9/2/2024 indicated Patient 1 was assessed to be dependent (helper does all of the effort, Patient does none of the effort to complete the activity) on staff to transfer to and from a bed to a chair, toileting, showering, and requires partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) to roll from lying on back to left and right side, and return to lying on back on the bed. A review of Patient 2’s Admission Record indicated Patient 2 is a 38- year- old male who was admitted to the facility on 9/4/2024 with diagnosis of encephalopathy (disease of the brain that alters brain function or structure) and bipolar disorder (a serious mental illness that causes extreme mood swings, from mania or hypomania to depression).  A review of Patient 2’s H&P dated 9/6/2024 indicated Patient 2 has the capacity to understand and make decisions. A review of Patient 2’s MDS dated 9/13/2024 indicated Patient 2 was assessed to require partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) to walk at least ten feet in a room, sit up in a chair, and transfer from a bed to a chair. During a concurrent observation in Patient 2’s room and interview on 10/29/2024 at 9:00 AM with Patient 2, Patient 2 was laying down in his bed, and stated that on 10/25/2024 he intentionally hit Patient 1 with his cane because Patient 1 refused to turn off the television (T.V.) in the room they shared. Patient 2 spoke loud and aggressively to the state surveyor and repeatedly stated the staff at the facility “is st*pid”. During an interview on 10/29/2024 at 9:16AM with Patient 1, Patient1 stated on the day of 10/25/2024 at approximately 10:30 AM, he was watching T.V. as is his usual routine while in his bed, meanwhile Patient 2 (Patient 1’s roommate at the time of incident) was in their room complaining out loud about staff and the facility. Patient 1 stated, Patient 2 kept yelling at Patient 1 to turn off the T.V., but Patient 1 refused to turn off the T.V. because he wanted to watch T.V. Patient 1 stated Patient 2 kept yelling at Patient 1 making threats that Patient 2 would send Patient 1 to the hospital, and Patient 2 got up to close the door of the room and walked over to Patient 1’s bed, raised Patient 2’s cane and Patient 2 hit Patient 1 with the cane. Patient 1 also stated he raised his arms to block the cane from hitting his face and head. Patient 1 stated Patient 2 continued yelling at him until a facility staff came (Licensed Vocational Nurse [LVN] 1). Patient 1 stated after the incident on 10/25/2024 occurred with Patient 2, Patient 1 has seen Patient 2 walk outside of Patient 1’s room and stand in the corner outside of Patient 1’s room just watching Patient 1 looking around his room. Patient 1 stated feeling intimidated by Patient 2 because Patient 1 cannot walk and defend himself. Patient 1 stated when Patient 1 saw Patient 2 stand outside his room, there was no facility staff directly supervising Patient 2. Patient 1 stated later that day (10/25/2024) his left wrist was red and swollen. Patient 1 also stated he still had pain on his left wrist when he touches it during the interview (on 10/29/2024). Patient 1 stated no one is safe in the facility while Patient 2 is in the facility. During an interview on 10/29/2024 at 12:00 PM with the Administrator, the Administrator stated, she was aware of the nurse’s notes about Patient 2 making threats about “killing people and blowing up this place”. During an interview on 10/29/2024 at 12:05 PM with the Director of Nursing (DON), the DON stated they (the facility staff) were relying on 1:1 monitoring/ sitter (trained healthcare professional who provides care and supervision to patients who need close monitoring) in the meantime to keep other Patients safe from Patient 2. The DON stated because of Patient 2’s past behavior which included verbal and physical threats to other patients, and because Patient 2 is unpredictable, patients were at risk for being hurt by Patient 2. The DON stated the incident between Patient 1 and 2 on 10/25/2024 could have been prevented by providing a 1:1 sitter to Patient 2. During an interview on 10/29/2024 at 12:46 PM with Registered Nurse (RN) supervisor, after the incident occurred on 10/25/2024 between Patient 1 and 2, Patient 1 had left lateral (side) wrist erythema (reddening of the skin as a result of injury or irritation), raised skin, and it was painful to touch. During an interview on 10/29/2024 at 2:00 PM with LVN1, LVN1 stated, on 10/25/2024, she went to answer the call light Patient 1 and 2’s room, and when she opened the door, Patient 1 told her that Patient 2 had hit him with a cane. LVN1 stated she saw Patient 2 standing over Patient 1’s bed holding a cane and asked Patient 2 why he hit Patient 1 with his cane. LVN1 stated Patient 2 told her that he hit Patient 1 with his cane because the TV was too loud. LVN1 stated she received orders from the doctor (unable to recall when) to put Patient 2 on 1:1 supervision/ sitter which means having an assigned certified nursing assistant (CNA) solely watching Patient 2 to ensure the patient is not a threat to others. LVN1 stated the assigned CNA watching Patient 2 should not have any other tasks at the same time such as attending to other patients or responsibilities while “sitting (watching)” Patient 2. A review of the facility’s policy titled Abuse Prevention and Prohibition Program dated 8/1/2023, indicated the facility is committed to protecting Patients from abuse by anyone. Staff must not permit anyone to engage in verbal, or physical abuse. The presence of a mental disorder or cognitive impairment does not automatically preclude a Patient from engaging in deliberate non-accidental behavior. A review of the facility’s policy titled “Patient to Patient Altercations” dated 8/1/2023 indicated, if after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the Patient to a more appropriate facility. The facility failed to protect Patient 1 from physical abuse by Patient 2. On 10/25/2024, Patient 2 hit Patient 1 with a cane. This deficient practice resulted in pain, redness and swelling to Patient 1’s left wrist, as well as anxiety. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.