complaint·September 15, 2022

This Department determined staff neglected R1 by failing to supervise R1 appropriately and failing to check on R1. Per facility key fob records, R1 was last seen in R1’s room on 3/20/2022 at 2:56 PM. Staff were unaware of R1’s whereabouts. Although a few staff stated they saw R1 on the morning of 3/22/2022, those statement did not match the key fob records for R1’s room door. There is a preponderance of evidence obtained, that R1 was last seen in R1’s room on 3/20/2022 at 2:56 PM and R1 never left the room until discovered on 3/22/2022 at 2:59 PM. R1 sustained an unwitnessed fall in R1’s room during this time period. R1 was discovered in R1’s room on 3/22/2022 at 2:59 PM when staff smelled “a really rancid urine smell” coming from the room of R1 which was what prompted staff to check on R1. Staff discovered R1 lying on the ground mostly nude and on R1’s left side. R1 was lying on a pool of urine described size as “a basketball or two.” Staff stated, “You could really smell it (urine). It was a lot.” R1 was “not fully aware” which is not R1’s baseline. At this time staff summoned for assistance to include 911. R1 was admitted to the hospital and diagnosed with a broken bone, pressure injuries and abrasions. Paramedics and medical staff (nurse and doctor) provided statements to support that the injuries were 1-2 days old. Blood work indicated R1 was incapacitated for at more than 8 hours which is evidence that R1 sustained the pressure injuries as a result of laying in a position for a prolonged period of time due to staff not checking on R1. Although staff stated they saw R1 the morning of 03/22/2022. Medical evidenced supports R1 was down for a prolonged period of time resulting in pressure wounds and abrasions, in addition to R1 sustaining a fractured femur as a result of R1’s fall. All staff interviewed, including facility Administrators admitted, although R1 was independent and did not need assistance for ADL’s, the facility policy was that every resident is checked on and accounted for at every meal. This is documented on the Resident Meal Checklist. The Resident Meal Checklist documents that R1 attended breakfast, lunch and dinner on 3/21/22, however, serving staff interviewed admitted that on occasion residents were checked off as receiving a meal that had not received a meal. It was documented that R1 did not receive breakfast or lunch on 3/22/2022 and was not checked on as per facility policy. Cont'd on LIC 9099C The preponderance of evidence supports that R1 did not receive timely medical attention due to staff neglecting to check on R1 when R1 missed Breakfast on 3/22/2022. Door key fob records obtained indicate that no one entered or exited Alice’s room after 03/20/2022 at 2:56 PM when R1 was last seen in her room. In an addition to the complaint allegations, additional deficiencies will be cited during a case management visit. Reference LIC 809 (Facility Evaluation Report). Based on observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.