Health inspection·October 10, 2024

T22 § 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. § 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. T42 F600 and F609 §483.12 Freedom from Abuse, Neglect, and Exploitation §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of patient property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 8/26/2024 an unannounced visit was conducted by California Department of Public Health (CDPH) to the facility for an employee to patient abuse allegation. The facility failed to protect the patient's right to be free from verbal abuse (a type of emotional abuse that uses language and communication to cause harm) by staff for Patient 1. The facility also failed to report the verbal abuse to CDPH, local law enforcement, and the state ombudsman (advocates for patients of nursing homes, board and care homes and assisted living facilities), within two (2) hours after the verbal abuse incident for Patient 1 in accordance with the facility's abuse prevention policy. These deficient practices had the potential for Patient 1 to feel powerless and unprotected and place Patient 1 and other patients at risk for further abuse, which could affect the patients’ emotional and psychosocial wellbeing. A review of Patient 1’s Admission Record, it indicated the patient was a 56 years old male who was initially admitted to the facility on 5/16/2006 and readmitted on 8/19/2012 with diagnosis that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Patient 1's History and Physical (H&P), dated 1/24/2024, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 8/9/2024, indicated Patient 1 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Patient 1 required substantial assistance (helper does more than half the effort) with toileting hygiene, shower, upper and lower body dressing, and putting on and taking off footwear. The MDS further indicated Patient 1 required partial assistance (helper does less than half the effort) with personal hygiene and setup assistance (helper sets up; patient completes activity) with eating and oral hygiene. A review of the Situation, Background, Assessment, and Recommendation (SBAR, developed to create a reliable consistent process to facilitate concise, clear, and focused communication), dated 8/12/2024, indicated that an Interdisciplinary Team Meeting (IDT, comprised of team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities) was held to address a complaint made by Certified Nurse Assistant 1 (CNA 1) against Patient 1. The SBAR report indicated that CNA 1 responded with "F_ _k you" after Patient 1 called him "F_g_ _t." The SBAR report further indicated that CNA 1 admitted to responding "F_ _k you" and expressed feelings of being upset and frustration towards Patient 1. During an interview on 8/26/2024 at 11 AM, Patient 1 stated he got into a fight with CNA 1 on 8/7/2024 and was upset and felt disrespected. Patient 1 also stated he told CNA 1 "F_ _k you" that day and CNA 1 responded by saying, "F_ _k you" back at him. During an interview on 8/26/2024 at 12:17 PM, the Restorative Nursing Assistant 1 (RNA 1) stated she witnessed CNA 1 when he shouted, "F_ _k you" to Patient 1 after the patient shouted, "F_ _k you f_ g_ _t" to CNA 1. RNA 1 also stated saying "F_ _k you" to a patient is a type of verbal abuse and should have been reported immediately within two (2) hours to the Administrator (ADM) to prevent escalation and for the safety of the patient. During an interview on 8/26/202424 at 11:46 AM, the Director of Staff Development (DSD) stated any alleged abuse should be reported within 2 hours to the Administrator (ADM). During an interview on 8/26/2024 at 2:30 PM, the Director of Nursing (DON) stated CNA 1's "F_ _k you" response is considered a verbal abuse and must be immediately reported to the ADM as indicated on the facility policy to ensure Patient 1's safety and to prevent further abuse. During an interview on 8/26/2024 at 2:42 PM, the ADM stated CNA 1's response to Patient 1 was not appropriate and was against the facility's policy. The ADM stated that the staff did not report the allegation of verbal abuse of CNA1 to Patient1. ADM stated the staff had the responsibility to report any allegations of abuse to him to ensure that it will be reported to DPH within 2 hours. A review of the facility's policy and procedure (P&P) titled, "Abuse-Prevention, Screening, and Training Program," revised July 2018, indicated that the facility does not condone any form of patient abuse ...and/or mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse. The policy also indicated that verbal abuse is defined as any use of oral, written, or gestured communication, or sounds that willfully includes disparaging (expressing the opinion that something is of little worth), and derogatory (insulting) terms directed to patients within their hearing distance, regardless of age, ability to comprehend, or disability. A review of the facility's policy and procedure (P&P) titled, "Abuse - Prevention, Screening, and Training Program," revised July 2018, the indicated that the facility provides, and staff sign an acknowledgement of their responsibility to report alleged or suspected abuse, neglect, exploitation, misappropriation of patient property and/or mistreatment. A review of the facility's P&P titled," Abuse Prevention and Management," revised 5/30/2024 with an effective date of 6/12/2024, indicated that allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the ADM or designated representative immediately. The ADM or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than 2 hours of initial report. The facility failed to protect the patient's right to be free from verbal abuse (a type of emotional abuse that uses language and communication to cause harm) by staff for Patient 1. The facility also failed to report the verbal abuse to CDPH, local law enforcement, and the state ombudsman (advocates for patients of nursing homes, board and care homes and assisted living facilities), within two (2) hours after the verbal abuse incident for Patient 1 in accordance with the facility's abuse prevention policy. These deficient practices had the potential for Patient 1 to feel powerless and unprotected and place Patient 1 and other patients at risk for further abuse, which could affect the patients’ emotional and psychosocial wellbeing. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and other patients in the facility.