complaint·May 9, 2024

.... Continued from LIC9099 The complaint alleges that staff did not ensure the resident was fed, resulting in the resident becoming severely malnourished. Medical records from R1’s hospitalization on 8/15/2023 revealed a diagnosis of severe protein-calorie malnutrition and weight loss. Those records indicated a weight loss of 34 percent over 16 months, from 188 pounds on 4/6/2022 to 123 pounds on 8/15/2023. When interviewed, the 3 staff members, Administrator (ADM) Lorica Hipolito, Caregiver S1, and Caregiver S2, stated that they had observed R1's loss of weight and change in condition during that period. They stated that R1 had an irregular sleeping pattern. R1 was awake for as many as 3 days in a row, followed by as many as 3 days of sleep. When awake, they reported that R1 had a good appetite. When R1 was asleep, R1 was not fed by the staff. Their neglect resulted in severe malnourishment and weight loss for R1. The complaint alleges that staff did not monitor R1's water intake, resulting in severe dehydration. When interviewed, all the 3 staff members, ADM, S1, and S2, stated that R1 had an irregular sleeping pattern. R1 was awake for as many as 3 days in a row, followed by as many as 3 days of sleep. All 3 staff stated that R1 was diabetic and would drink lots of water when awake. When R1 was asleep, R1 was not given any fluids by the staff. Their neglect resulted in R1 going for as many as 3 days in a row without drinking any fluids. R1’s hospital medical records revealed that on 8/15/2023 R1 was diagnosed with severe dehydration, which resulted in R1 experiencing an altered mental state due to a metabolic encephalopathy caused by R1’s dehydration superimposed on a Urinary Tract Infection (UTI). The complaint alleges that R1 developed a pressure injury while in care. R1’s hospital medical records revealed that R1 was diagnosed with an unstageable right ischial tuberosity pressure injury on 8/15/2023. R1 did not have any other records with the hospital documenting a history of pressure injuries for R1. Interviews with ADM and S1 revealed consistent statements of having knowledge about R1's pressure injury. ADM admitted that R1 had a pressure injury on R1’s buttock that was difficult to locate. ADM and S1 had conflicting statements about the stage of R1’s right ischial pressure injury. ADM denied seeing R1's pressure injury at the size and stage of that for which R1 was diagnosed on 8/15/2023 at the hospital. Continues on LIC9099-C2 . . . .... Continued from LIC9099 -C1 The complaint alleges that R1 developed a UTI while in care. R1’s hospital medical records revealed that on 8/15/2023, R1 was diagnosed with a Urinary Tract Infection (UTI). Medical records indicated that R1's UTI was a result of being malnourished and dehydrated. Interviews of ADM and S1 revealed inconsistent statements regarding R1's urine. ADM admitted observing R1 with discharge coming from R1’s penis about a week prior to R1 being transported to the hospital on 8/15/2023. ADM and S1 denied that R1 was in pain or needed assistance urinating. ADM and S1 denied that R1's urine had a foul odor or an unusual color. The complaint alleges that staff did not seek medical attention for R1 in a timely manner. R1’s hospital medical records revealed that on 8/15/2023, R1 was taken to the hospital by ambulance after the RP called 911. R1 was then diagnosed with dehydration, severe malnourishment, an unstageable right ischial pressure injury, and UTI. R1 was also diagnosed with experiencing an altered mental state due to metabolic encephalopathy caused by R1’s dehydration superimposed on R1’s UTI. Interviews with ADM and S1 revealed consistent statements of communicating R1’s change in condition with the RP and R1’s Primary Care Physician (PCP). ADM and S1 agreed that after communicating R1’s health with the RP and PCP, they did not take additional steps to address R1's declining health. ADM and S1 stated that R1's health was declining during 2023 and they failed to seek timely medical attention and that not seeking medical attention during that time resulted in the illnesses listed above. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D. A $500.00 immediate civil penalty is assessed today. Licensee was informed that an additional civil penalty is still being determined based on Health & Safety Code 1569.49(f). Exit interview conducted with Licensee and a copy of this report was provided.