Chino Valley Health Care Center
2351 S. Towne Ave., Pomona, CA 91766
Citation Number: 950009835
Citation Date: 3/25/2014
Violation Date: 11/23/2010
Class: AA
Penalty: $ 100,000

CLASS AA CITATION-- PATIENT CARE

F223 483.13(b)-The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion.

On November 30, 2010 at 8:15a.m., an unannounced visit was made to the facility to investigate an entity reported incident that occurred when Resident A was found with a bloody face and an injured right arm from an unknown origin at 9 a.m., on November 23, 2010.

The facility failed to ensure that Resident A was free of physical abuse by failing to:

  1. Develop Resident B's care plan to include specific time tables to meet the supervision/monitoring needs of the resident who had physically abusive and socially inappropriate aggressive behavior toward others.
  2. Revise Resident B's care plan interventions when the resident did not meet the expected care plan goal of less than two episodes of sudden angry outburst behavior every month to address the resident's physically abusive and socially inappropriate behavior.
  3. To appropriately address Resident B's aggressive behaviors and intervene to prevent abuse of Resident A

As a result, Resident B physically assaulted Resident A which subsequently resulted in Resident A's emergency hospitalization at an acute care hospital. Resident A received acute hospital treatment on November 23, 2010 at 10:06 a.m., where he was diagnosed with traumatic open elbow dislocation and facial trauma.

Resident A remained in the acute care hospital from November 23, 2010 until his death on December 4, 2010. Resident A's death was due to multiple blunt force injuries including injury to the right elbow I amputation of the right arm.

A review of Resident A's medical record indicated he was a 91 year old male who was admitted to the skilled nursing facility (SNF) on September 11, 2009, with diagnoses that included diabetes mellitus, vascular dementia (cognitive [mental] and intellectual deterioration) and prostate cancer.

The Minimum Data Set (MDS, a standardized assessment and care planning tool), dated September 6, 2010, indicated that Resident A had short and long term memory problems, had severely impaired cognitive skills for daily decision making and rarely made himself understood. The resident sometimes was able to understand others and had unclear speech. The MDS further indicated that Resident A was non-ambulatory, used a wheelchair for locomotion and was totally dependent on others for most activities of daily living.

A review of Resident A's a care plan initiated on September 11, 2009, titled "At risk for fall and injury due to poor safety awareness related to diagnosis of dementia", indicated that staff would maintain visual checks when Resident A was up in wheelchair and when in bed.

A review of Resident B's admission record indicated that the resident was a 46 year old male resident who was originally admitted to the SNF on February 24, 2009, and was readmitted to the SNF on May 21, 2010, with diagnoses of altered level of consciousness, status post (S/P, refers to a state that follows an intervention) craniotomy (brain surgery) and VP shunt (ventriculoperitoneal shunting is surgery to relieve increased pressure inside the skull) placement, seizure disorder dementia with behavior disturbance and paraplegia.

The annual MDS of February 9, 2010, indicated that Resident B had short and long term memory problems and was moderately impaired in cognitive skills, had persistent anger with self or with others, required limited assistance with locomotion on the unit and with eating, had paraplegia (paralysis of the lower part of the body), and had an anxiety disorder. The Resident Assessment Protocol Summary (RAPS) dated February 9, 2010, indicated that the resident had angry outbursts, aggressive behavior toward others and the facility would proceed with a care plan.

According to the SNF transfer record dated September 3, 2010 at 6 p.m., Resident B was transferred to an acute care hospital for having destructive behavior. A "Nursing Alert" from the SNF dated September 3, 2010, indicated that Resident B was "destructive to equipment ... had very strong upper body strength."

The psychiatric evaluation assessment from the acute hospital dated September 4, 2010, indicated that Resident B had multiple prior admissions due to destructive behavior. The medical and history from the acute hospital dated September 4, 2010, disclosed that Resident B was admitted to an acute hospital for psychiatric treatment and that Resident B stayed at the acute hospital for ten days and was readmitted to the SNF on September 13, 2010.

A review of Resident B's physician's orders dated September 13, 2010, indicated the following medications were ordered:

  1. Seroquel (an antipsychotic medication) 100 mg by mouth twice a day.
  2. Seroquel 150 mg every bedtime for psychosis manifested by constant talking to self.
  3. Ativan one mg by mouth every four hours whenever necessary for anxiety manifested by sudden angry outburst behavior.

On September 13, 2010, a care plan was initiated due to Resident B receiving Ativan resulting from sudden angry outburst behavior due to anxiety. The care plan approaches included the following:

  1. Administer medication as ordered
  2. Monitor and record episodes of sudden angry outburst behavior
  3. Summarize effectiveness of data monthly

The SNF Roster of November 23, 2010, revealed Resident A was a roommate of Resident B.

Resident B's MDS dated September 23, 2010, (2 months prior to his discharge of November 23, 2010), revealed that Resident B was assessed to have verbally abusive, physically abusive, socially inappropriate, and disruptive behaviors. The resident was also assessed as non-ambulatory, used a wheelchair for locomotion ·and needed extensive assistance for most activities of daily living.

The care plan goal of September 13, 2010, indicated that Resident 8 would have less than two episodes of sudden angry outburst behavior every month. The care plan intervention of monitoring episodes of sudden angry outburst behavior did not include the method of monitoring or supervising the resident and did not specify time tables for supervision or monitoring of Resident 8 to ensure that Resident A and other residents were not subjected to Resident's 8's angry and aggressive outbursts. Additionally, the care plan indicated to summarize effectiveness of data monthly, however, the care plan did not indicate how to intervene in the event that the medication (Ativan) was not effective in reducing Resident 8's sudden angry outburst behavior to less than two episodes of this type of behavior every month as indicated in the care plan goal.

A review of the medication administration record (MAR) of September 13, 2010 to September 30, 2010 revealed Resident 8 was given Ativan one milligram (mg) by mouth 6 times during this time frame.

A review of the medication administration record (MAR) of October 1, 2010 to October 31, 2010, revealed Resident 8 was given Ativan one milligram (mg) by mouth 25 times during this time frame.

A review of the medication administration record (MAR) of November 1 to 23, 2010, revealed Resident 8 was given Ativan as needed one milligram (mg) by mouth 17 times during this time frame. However, there was no evidence that the resident's sudden angry outburst behavior episodes diminished during the same time period from September 13, 2010 to November 22, 2010.

A review of the medication administration record (MAR) behavior monitoring for sudden angry outburst behavior of Resident 8 revealed the following:

a. Resident 8 had 31 episodes of sudden angry outburst behavior (in 16 days) from September 13, 2010 through September 30, 2010.

b. Resident 8 had 72 episodes of sudden angry outburst behavior (in 31 days) from October 1, 2010 through October 31, 2010.

c. Resident 8 had 55 episodes of sudden angry outburst behavior (in 23 days) from November 1, 2010 through November 23, 2010.

Resident B's sudden angry outburst behaviors had been summarized on the Psychotropic Summary Sheet as follows:

September 13, 2010 to September 30, 2010 - 30 behaviors
October 1, 2010 to October 31, 2010 - 72 behaviors

The behavior data was signed by the nurse, however, there was no indication that the behavior was analyzed from September 13, 2010 to November 23, 2010, to determine if Resident B's behavioral disturbance could be minimized by an increase in the dose or time interval of the Ativan.

The physician progress note dated November 5, 2010, indicated that Resident B had no new medical problems but had psychiatric aggression and that the resident's mental status was very labile (undergoing frequent change). There was another physician progress note of November 18, 2010, indicating that the resident's Seroquel was decreased on November 18, 2010, from Seroquel 100 mg twice a day and Seroquel 150 mg at bedtime to Seroquel 100 mg twice a day and Seroquel 100 mg at bedtime.

On November 23, 2010 at 10:30 a.m., Staff 1 was interviewed. Staff 1 stated on November 23, 2010 at approximately 8:45a.m., she responded to "Stat" (immediately) paging by a licensed staff in the secured unit (South Station) for Room 126.

During an interview on December 23, 2010 at 1:05 p.m., Staff 2 stated that on November 23, 2010, she passed the breakfast trays for Residents A and B in Room 126 at approximately 7:30a.m. At approximately 7:50a.m., she picked up the breakfast tray for Resident B, while Staff 4 was feeding Resident A in bed at that time. Staff 2 stated that she observed Residents A and Bin their beds at 8:30a.m., 15 minutes prior to the incident. Staff 2 also stated that at approximately 8:45 a.m. on November 23, 2010, she brought the wheelchair into the room for Resident B, and saw Resident A in his bed and his face was covered with blood.

During an interview on December 23, 2010 at 2 p.m., Staff 3 stated on November 23, 2010, between 8:45a.m., and 9 a.m., he followed Staff 2 to Room 126. Staff 3 stated that Staff 2 screamed for someone. to call 911 while at the entrance door of Room 126. Staff 3 stated that Resident A had blood on his face with swelling and discoloration below the eyes. The resident's right upper arm was pointed up over the right side rail and his right forearm was twisted around and pointed down between the bedside rail and mattress. The resident's right fingers were gripping the bottom of the right side rail, his humerus (the longest and largest bone of the upper arm) bone was fully exposed approximately four inches and his right elbow joint was totally displaced. The resident was awake but non-communicative in bed, his side rails were up and he was leaning towards the right side of bed. There was blood on the right side rail and the right side of the mattress of Resident A.

According to Staff 3, Resident B was sitting on the floor at the foot of Resident A's bed. Resident B had blood on his hands and gown. Staff 3 stated Resident B had behavioral problems such as being loud, using foul language and tossing meal trays to the ground. Resident B was able to transfer himself from bed to wheelchair using both arms and would scoot on his buttocks on the floor to use the bathroom. Staff 3 stated there was no specific frequency as to how often Resident B would be monitored by staff for his sudden angry outburst behavior.

During an interview on October 2, 2012 at 2:35p.m., Staff 4 disclosed that she did not remember going to Room 126 until approximately 8:50a.m., when another co-worker had told her that an incident occurred in Room 126.

According to Resident B's licensed nurse note dated November 23, 2010 at 2 p.m., Resident B was discharged to an acute hospital for further evaluation of his behavior because he was observed with blood on his hands and gown on the floor at the foot of Resident A's bed.

The acute hospital psychiatric initial evaluation and mental status examination dated November 23, 2010, indicated that Resident B who lived at the SNF, became aggressive and pulled the arm of a resident in the facility.

According to licensed nurse record dated November 23, 2010 at 9 a.m., Resident A was observed in bed with blood on his face and the skin on his right elbow was bleeding. On November 23, 2010 at 9:30a.m., the physician ordered Resident A to be transferred to an acute hospital via 911.

Resident A required transfer from the SNF by EMS helicopter to an acute hospital emergency department where Resident A was diagnosed with traumatic open elbow dislocation, and facial trauma. The Emergency Nursing Data Base and Flow Record indicated Resident A arrived at the acute facility on November 23, 2010 at 10:06 a.m.

According to the acute hospital orthopedic consult note dated November 23, 2010, at 4:56p.m., Resident A per EMS (emergency medical services) was found (at the SNF) wedged between his bed and a wall.

The acute hospital orthopedic consult note dated November 23, 2010 at 4:5.6 p.m. also indicated the resident's right arm injury was described as follows: There was a 14 centimeter laceration (cut) overlying the anterior antecubital fossa (front aspect of the elbow) proceeding around the medial and lateral (middle and back side of the elbow) aspects. There was a 4 centimeter skin bridge posteriorly (back side) behind which part of the triceps tendon seems to be intact. The resident's right elbow joint was reduced (restored to the normal place), irrigated (washed) and was placed in stabilization splint. Further the consult note indicated the resident was a candidate for an emergency operative reduction and external fixator placement (surgery to correct the injury) at right elbow but was the surgery was cancelled when the resident was designated for comfort care only (on December 2, 2010).

Resident A remained in the acute care hospital from November 23, 2010, until his death on December 4, 2010. The death memorandum record disclosed that Resident A had passed away on December 4, 2010, at 5:04 a.m. and the cause of death was due to amputation of the right arm and facial trauma. The Autopsy report dated December 14, 2010, revealed that Resident A's death was due to multiple blunt force injuries. The injuries included ecchymosis (bruising) of face and upper extremities, laceration of the right arm and status post dislocation of the right elbow. According to the opinion of the deputy medical examiner, the resident's manner of death was homicide.

Attempts to obtain the police department investigation report of the incident, during the Department investigation failed.

A review of the facility's undated policy and procedure for abuse prevention stipulated the following "'any aggressive behaviors will be addressed immediately"' using intervention methods, including "'Place resident with behaviors on a 24-hour observation"' and "'Transfer resident if necessary'."

"Residents with possible needs and potential for behavioral symptoms and manifestations that may lead to conflict and anger and neglect shall be identified through comprehensive assessments, initially upon the resident's admission, and continuously thereafter, as deemed appropriate and necessary." "Residents identified to have behavioral symptoms potential for conflict and anger shall be monitored in accordance with plans of care developed to address such problems. Monitoring of such residents shall be the responsibility of, but not limited to, direct caregivers, Charge nurses, Nursing Supervisors, and members of the interdisciplinary team."

The facility failed to ensure that Resident A was free of physical abuse by failing to:

  1. Develop Resident B's care plan to include specific time tables to meet the supervision/monitoring needs of the resident who had physically abusive and socially inappropriate aggressive behavior toward others.
  2. Revise Resident B's care plan interventions when the resident did not meet the expected care plan goal of less than two episodes of sudden angry outburst behavior every month to address the resident's physically abusive and socially inappropriate behavior.
  3. To appropriately address Resident B's aggressive behaviors and intervene to prevent abuse of Resident A.

As a result, Resident B physically assaulted Resident A which subsequently resulted in Resident A's emergency hospitalization at an acute care hospital. Resident A received acute hospital treatment on November 23, 2010 at 10:06 a.m., where he was diagnosed with traumatic open elbow dislocation, and facial trauma.

The facility failed to develop and revise Resident B's care plan, appropriately address Resident B's aggressive behaviors, and intervene to prevent abuse of Resident A: These failures led to Resident B's assault on Resident A that resulted in a severe, traumatic, open elbow dislocation injury to the right elbow and facial trauma that led to the death of Resident A on December 4, 2010.

The violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and was a direct proximate cause of the death of Resident A.