Health inspection·June 12, 2024

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;

F609 483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

F600 The facility failed to: 1. Prevent an incident of verbal abuse (a range of words or behaviors used to manipulate, intimidate, and maintain power and control over someone) for Patient 1 when Patient 2 called Patient 1 racial (discrimination and prejudice against people based on their race or ethnicity) slurs (an insinuation or allegation about someone that is likely to insult them or damage their reputation) and Patient 2 attempted to hit and spitted at Patient 1. 2. Report within two hours to the state agency CDPH, the state ombudsman (advocates for patients of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) of an allegation of verbal abuse (a range of words or behaviors used to manipulate, intimidate, and maintain power and control over someone) for Patient 1. These deficient practices placed Patient 1 at risk for psychosocial harm such as feeling unsafe and anxious and at further risk of more episodes of verbal abuse by Patient 2. During a review of Patient 1's Admission Record the patient a 36 year old female was originally admitted to the facility on 3/29/2024 with diagnoses of post-traumatic stress disorder (PTSD; a disorder that develops when a person has experiences or witnessed a scary, shocking, terrifying, or dangerous event) and anxiety disorder (a condition which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Patient 1's History and Physical Examination (H&P), dated 3/30/2024, H&P indicated the patient is competent to understand her medical condition. During a review of Patient 1's Minimum Data Set (MDS - a standardized patient assessment care screening tool), dated 4/4/2024, the MDS indicated the patient was cognitively intact (ability to think, remember, and reason), and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity) for transfers (how patient moves to and from bed, chair, wheelchair, standing position), walking, toileting, dressing (how a patient puts on, fastens and takes off all items of clothing), and personal hygiene and was independent with eating. During a review of Patient 2's Admission Record indicated Patient 2, a 71 year old female was originally admitted to the facility on 3/27/2024 diagnoses of metabolic encephalopathy (damage or disease that affects the brain) and cerebral infarction (damage to the tissues in the brain due to a loss of oxygen). During a review of Patient 2's H&P, dated 1/19/2024, H&P indicated the patient is not competent to understand her medical condition. During a review of Patient 2's MDS, dated 4/2/2024, MDS indicated the patient was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) decision making, and needed supervision or touching assistance with transfers, walking, dressing and personal hygiene and was independent with eating. During a record review of Patient 1's progress note dated 4/9/2024 at 11:12 PM signed by Licensed Vocational Nurse 1 (LVN 1), Patient 1's progress note indicated Patient 1 came to the nurses station to complain to LVN 1 that Patient 2 was using racist slur language towards her and that LVN 1 observed Patient 2 attempt to hit Patient 1 and spitted at Patient 1. During an interview on 4/17/2024 at 10:05 AM with Patient 1, Patient 1 stated that on 4/9/2024, she got into an argument with her roommate, Patient 2. Patient 1 also stated, after speaking with LVN 1 at the nurse’s station, Patient 1 stated, as she was walking back in her room, Patient 2 called her a racial slur in front of LVN 1. Patient 1 then stated that moments later at the nurse’s station, she was expressing to LVN 1 that she did not feel safe due to being called a racial slur by Patient 2, and in that moment Patient 2 came out of the room yelling at her and continuing to call her racial slurs and spit at her in front of LVN 1. During an interview on 4/17/2024 at 10:54 AM with LVN 1, LVN 1 stated on 4/9/2024 around 10:30 PM, Patient 1 came up to the nurse's station stating that Patient 2 had called Patient 1 a racial slur and did not want Patient 2 in her room. LVN 1 then stated Patient 2 overheard them talking and started yelling at Patient 1and spit at her. During an interview on 4/17/2024 at 11:26 AM with Certified Nursing Assistant (CNA), CNA stated that on 4/9/2024, Patient 1 and Patient 2 got into a disagreement and when Patient 1 came up to the nurse's station to ask LVN 1 to change rooms or de-escalate (to decrease in intensity) the situation, Patient 2 came out and called Patient 1 a racial slur. CNA also stated that after Patient 2 was separated from Patient 1, the staff had her sitting in the hallway where Patient 2 continued to yell out the racial slurs toward Patient 1 for about 5 to 10 minutes. During an interview on 4/17/2024 at 12:01 PM with Minimum Data Set Nurse (MDSN), MDSN stated that he would consider a person yelling out racial slurs towards another person as verbal abuse and that someone trying to hit and spit would also be considered abuse. During an interview on 4/17/2024 at 12:15 PM with LVN 2, LVN 2 stated he would consider someone yelling racial slurs at another person verbal abuse. During a concurrent interview and record review on 4/17/2024 at 12:26 PM with Registered Nurse (RN), Patient 1's progress note dated 4/9/2024 at 11:12 PM signed by LVN 1 was reviewed. Patient 1's progress note indicated an altercation of Patient 2 calling Patient 1 a racial slur and attempting to hit and spitted at her. RN stated that she would consider calling someone a racial slur as verbal abuse and stated in the incident between Patient 1 and Patient 2, they should have been immediately separated and monitored to make sure the patients were okay. RN also stated the incident should have been reported to CDPH, Ombudsman and local PD within 2 hours timeline as well as the patients' primary doctors to see if there were any interventions that needed to be ordered such as a psychiatry (the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) consultation. During an interview on 4/17/2024 at 1:40 PM with Social Services Director (SSD), SSD stated she considers derogatory (intended to lower the reputation of a person or thing) terms and racial slurs verbal abuse and stated that in that instance, Patient 1 and 2 should have been separated and monitored to make sure the patients were okay. SSD also stated that it is important to assess patients for their possible triggers so that they could feel safe in the facility and if ever Patient 1 expressed feelings of not feeling safe RN would monitor Patient 1 and ask the patient what RN could do to help change that. During a concurrent interview and record review on 4/17/2024 at 2:36 PM with MDSN, Patient 1's progress note dated 4/9/2024 at 11:12 PM signed by LVN 1 was reviewed, Patient 1's progress note indicated an altercation of Patient 2 calling Patient 1 a racial slur and attempting to hit and spit at her. MDSN stated that the incident should have been reported by LVN 1. During an interview on 4/17/2024 at 3:15 PM with LVN 1, LVN 1 stated the incident she witnessed between Patient 1 and 2 on 4/9/2024 should have been reported to CDPH, local PD and ombudsman. LVN 1 also stated she should have documented better and called the Administrator to let her know about the situation. During a review of the facility's police and procedure (P&P) titled "Preventing Patient Abuse" revised December 2013, the P&P indicated, "Our facility will not condone any form of patient abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing patient abuse," with the policy interpretation and implementation stating: " The facility's goal is the achieve and maintain an abuse-free environment. " Instructing staff about how cultural, religious and ethnic differences can lead to misunderstanding and conflicts; " Monitoring staff on all shifts to identify inappropriate behaviors towards patients (for example [e.g.], using derogatory language). During a review of the facility's policy and procedure (P&P) titled "Abuse Prevention Program" revised December 2016, the P&P indicated, "Our patients have the right to be free from abuse." The P&P also indicated the abuse includes verbal abuse and the administration will: " Protect our patients from abuse by anyone including, but not necessarily limited to: facility staff, other patients, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. " Identify and assess all possible incidents of abuse. During a review of the facility's policy and procedure (P&P) titled "Abuse Prevention Program" revised December 2016, the P&P indicated, "As part of the resident abuse prevention program, the administration will investigate and report any allegation of abuse within timeframes as required by federal requirements." During a review of the facility's policy and procedure (P&P) titled "Abuse Investigation and Reporting" revised July 2017, the P&P indicated: " "All alleged violation involving abuse, neglect (a situation in which you do give enough care or attention to someone or something), exploitation (the act of selfishly taking advantage of someone or a group of people in order to profit from them or otherwise benefit oneself), or mistreatment (when behavior shows disrespect for the dignity of others), including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: o The State licensing/certification agency responsible for surveying/licensing the facility; o The local/State Ombudsman; o The Resident's Representative (Sponsor) of Record; o Law enforcement officials; " An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but no later than: * Two (2) hours if the alleged violation involves abuse. The facility failed to: 1. Prevent an incident of verbal abuse (a range of words or behaviors used to manipulate, intimidate, and maintain power and control over someone) for Patient 1 when Patient 2 called Patient 1 racial (discrimination and prejudice against people based on their race or ethnicity) slurs (an insinuation or allegation about someone that is likely to insult them or damage their reputation) and Patient 2 attempted to hit and spitted at Patient 1. 2. Report within two hours to the state agency CDPH, the state ombudsman (advocates for patients of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) of an allegation of verbal abuse (a range of words or behaviors used to manipulate, intimidate, and maintain power and control over someone) for Patient 1. These deficient practices placed Patient 1 at risk for psychosocial harm such as feeling unsafe and anxious and at further risk of more episodes of verbal abuse by Patient 2. These violations had a direct or immediate relationship to the health, safety, or security of Patient 1.