complaint·August 9, 2022

A medical professional's orders were not followed (Resident 1) . During the investigative process, five staff persons and other persons were interviewed. Two staff persons that were working during the time of the incident, were not available for an interview. Numerous documents were obtained to include Physician’s Report, Admission Agreement, Medications List, Resident Roster, Death Report, Incident Report, Staff Roster, Police Reports and Fire Department Reports. During the interview process, it was reported that on 03/23/22, a medical professional verbally gave an order to a staff person to contact her, to advise if her patient/resident had any type of change or decline in his health. During the course of the conversation, the staff person did not advise the medical professional that the resident had been sick for several days prior, as the staff person indicated that she had been off of work for those few days and was not aware of the resident’s decline in health. It was reported that the resident had been ill for a few days and on 03/24/22, at approximately 0300 hours, staff observed that the resident had black dark liquid vomit and diarrhea. Two staff persons were on shift; however, neither of them called Emergency Services (911) to have the resident examined. It was stated that in the morning at approximately 0630 hours, the resident was dressed and coming down the hallway when he collapsed, continued to vomit black dark liquid, became unconscious and died. The facility staff are responsible to notify the resident’s physician when a resident’s mental or physical health changes. Although the staff person acknowledged that she received the verbal order, other staff persons working, were not informed of the verbal order, and no one notified the medical professional of the resident’s decline in health. Based on LPAs 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 . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Staff did not seek timely medical attention (Resident 1) . During the investigative process, seven staff persons, other persons and two residents were interviewed. Numerous documents were obtained to include Physician’s Report, Admission Agreement, Medications List, Resident Roster, Death Report, Incident Report, Staff Roster, Police Reports and Fire Department Reports. It was reported that the resident had been ill for a few days with the flu and on 03/24/22, at approximately 0300 hours, staff observed that the resident had black dark liquid vomit and diarrhea. There were two staff persons on shift; however, neither of them called Emergency Services (911) to have the resident examined. It was stated that it was the responsibility of the lead medication technician that should have called 911. When the medication technician did not call, the backup care provider should have called 911; however, she stated that that it was the responsibility of the medication technician. Neither staff persons contacted 911 and did not seek timely medical attention. It was stated that in the morning, at approximately 0630 hours, the resident was coming down the hallway when he collapsed, continued to vomit black dark liquid, became unconscious, and died. Based on LPAs 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 . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” The facility is being advised that under H&S Code §1568.0822(f) the issuance of an Enhanced Civil Penalty (ECP) is currently under review and may be assessed later, due to a resident sustaining (as defined above) serious bodily injury while in care of the facility. continued Medication Dosage is Inaccurate (Resident 1) . During the investigative process, five staff persons and other persons were interviewed. Two staff persons that were working during the time of the allegation were not available for an interview. Numerous documents were obtained to include Physician’s Report, Admission Agreement, Medications List, Resident Roster and Staff Roster. It was reported that on 11/02/21, a resident’s medication of Losartan Potassium was increased from 1 tablet to 1.5 tablets. In March 2022, it was documented that the resident was only receiving 1 tablet of Losartan Potassium, rather than the prescribed order of 1.5 tablets. Records indicated that the error was corrected on 03/15/22. Based on LPAs 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 . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.