complaint·October 20, 2023

Allegation: Staff not providing accurate dosage of medications to resident Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s admission agreement showed R1 was first admitted at the facility on 08/21/2021. Due to a change in condition, staff sent R1 to the hospital on 08/06/23, was admitted for treatment of physical deconditioning and discharged back to the facility on 08/12/23 with hospice care. Administrator (ADM) and authorized representative (POA) agreed to implement R1’s written hospice care plan (comfort measures only) dated 08/12/23 prior to the initiation of R1’s hospice care. ADM implemented R1's hospice care plan starting 08/12/23 until 08/15/23. Review of hospice care’s physician’s order dated 08/15/23 show R1’s comfort drugs dosages were increased by the hospice care physician to manage R1’s pain and anxiety. LPA interviewed ADM who stated that she refused to implement R1’s increased comfort drug dosages on 08/16/23 because she is a hospice nurse and did not believe in the hospice physician’s assessment. POA and family had to implement hospice doctor’s orders for increased comfort drug dosages until R1 passed on 08/19/23. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff was not providing accurate dosage of medications to resident was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. S3 stated S1 was the main caregiver of R1 and was no longer employed at the facility. LPA was unable to reach S1 by phone. Review of hospice records dated 8/14/23 showed hospice nurse noted R1 had blancheable pink area to bilateral heels on feet and instructed staff to float heels to avoid potential risk of the development of pressure sore(s). Hospice nurse did not observe or report presence of any pressure injuries on R1 during visits. Review of hospice notes dated 08/12/23 thru 8/15/23 showed hospice nurses assisted staff in changing and repositioning R1 and instructed staff on the proper technique for turning and repositioning R1 every 2 hours with heels floated to avoid the risk of pressure injuries. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff was not rotating and repositioning resident resulting in pressure sore(s) and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff was not rotating and repositioning resident resulting in pressure sore(s) is unsubstantiated. Allegation: Staff left resident in soiled diapers resulting in resident sustaining redness in private area Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM, S3) who denied leaving R1 in soiled diapers for extended periods of time resulting in redness in private area. Staff stated they followed R1’s hospice care plan and changed R1’s diapers frequently. Review of R1’s hospice care records dated 08/12/23 thru 08/19/23 did not show resident sustained redness in private area while in care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff left resident in soiled diapers resulting in resident sustaining redness in private area and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff left resident in soiled diapers resulting in resident sustaining redness in private area is unsubstantiated. Exit interview conducted and a copy of this report provided.