complaint·July 30, 2021

9099C(1)..Allegation: Resident was severely dehydrated while in care- Resident was sent to the hospital and admitted multiple times while residing at the facility. Hospital medical records reviewed from 12/24/2019 document that resident was diagnosed with “near syncope, dysrhythmia, anemia and dehydration ” and was given antibiotics for a Urinary Tract Infection and recommendations to stay well hydrated and to follow up with primary care physician in 1-3 days for recheck and further management. Hospital medical records from 2/20/2020 show resident was sent to the emergency room following a witnessed mechanical fall. Hospital conducted a head CT which showed no changes since the prior imaging was done in December 2019. There is no mention of dehydration. Hospital medical records from 3/9/2020 document that resident was admitted to the hospital after being sent to the emergency room following being found on the ground and observed to be more altered than her baseline, thought to have had a possible stroke. Records note that resident had acute kidney injury believed to be possibly due to dehydration and was given IV fluid for dehydration . Facility reassessment was done on 3/14/2020 which noted resident to be bed bound, to have a catheter, and to have failed a swallow test and to not take any food or drink by mouth. On 3/15/2020, resident was discharged with acute encephalopathy, acute kidney injury, advanced dementia and other conditions. Resident was placed on hospice care upon discharge back to facility. On 11/8/2020 was hospitalized due to altered mental status and diagnosed with hypernatremia, acute kidney injury, creatinine dehydration and urinary tract infection and high blood sugar and was admitted to ICU for insulin drip and received D5 for hypernatremia and 3 days of IV antibiotics and IV insulin and two normal saline boluses. Resident was discharged on 11/13/2020 with a Urinary Tract Infection, HHS, hypernatremia and acute kidney injury. MAR records show facility was correctly following blood sugar orders on 1 1/8/202 0 which was to check levels weekly. MAR shows blood sugar was tested on 11/3/2020 and was not due to be tested again until 11/10/2020. Orders to check blood sugar were changed from weekly to twice daily on 11/20/2020. Facility completed a change of condition assessment on 11/13/2020, following resident being discharged and returning to the facility. The assessment reflects resident requiring additional assistance, including observation, during meals due to eating difficulties, as well as additional special medical needs, specifically requiring status checks with each shift due to recent hospitalization, illness, medication change, etc. cont on 9099C(2).. 9099C(2).. Resident was re-admitted to the hospital on 11/15/2020 due to altered mental status and found to have acute kidney injury and hypernatremia and received IV fluids to treat both. Resident was discharged on 11/19/2020 on hospice. Based on information obtained, the department finds allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility restricted visitation Interviews conducted and documentation reviewed revealed that resident’s (R1) visitation rights were restricted from October 2019, when resident moved in, through August 19, 2020, when a conservator was appointed by court. Minute orders from 8/19/2020 appointment specifically order that “any family member is allowed to visit with (R1) as long as the visits are consistent with the policies of Oakmont”. Prior to the appointment of the conservator, facility staff were instructed to request that specific visitors be granted permission by resident’s Power of Attorney before being allowed to visit resident. Additionally, family members were told by the facility to reach out to the POA regarding medical status updates for resident. Interviews with the Conservator, prior Administrator and Regional Director of Health further concluded that there were no restraining orders in place pertaining to resident. Based on information obtained, the department finds allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) deficiencies are cited. (see 9099D page). Exit interview. Copy of report and appeal rights printed/provided to Administrator. 9099C(1)..Interview with Memory Care Director revealed that resident was “a great eater” and would drink 2-3 cups of liquid with her meals . Documentation shows resident’s condition did decline and facility assessment completed on 3/14/2020 notes that resident had increased difficulty with swallowing and had failed a swallow test when she was placed on hospice in March 2020. Resident was taken off of hospice on/around July 2020 , as requested by resident's family member/POA. . and was placed on hospice again in November 2020 through July 2021, when she passed. Conservator stated that facility followed resident’s care plan and when staff observed resident to be declining, hospice was initiated. Care staff who cared for resident for a year stated that resident was on pureed food and drinks and she would feed resident with a spoon and resident could drink with a straw, adding that resident "did not lose a lot of weight" as she ate pretty well always, except for the last 3 days, as she approached passing”. Facility weight records document that resident weighed 121 lbs in October 2019, upon move in, and weighed 123.6 lbs on 11/21/2019. Records show that resident weighed 115.2 lbs January 2020, 99 lbs in April and 107 lbs in October 2020. Resident weighed 107.2 in February 2021, 109 in March 2021, and 106 lbs in June 2021. Based on information obtained, the department finds the allegation to be UNSUBSTANTIATED-A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility retained a resident beyond their level of care Resident was admitted in October 5, 2019. Pre-Assessment dated 10/5/2019 indicates resident needed assistance with grooming, bathing, dressing, medication and with fall management. Initial Assessment dated 10/14/2019 notes changes with additional assistance needed with dressing and medications and toileting assistance being added. Facility sent a letter dated 10/18/2019 to resident’s POA to advise that resident’s care level had increased from level 2 to level 3. Resident was reassessed on 3/14/2020 due to resident showing a decline with mental/physical capabilities due to possible stroke; speech unintelligible, unable to walk but can bear weight; advanced Dementia stage IV, increased agitation, high fall risk. Resident was placed on hospice initially on 3/15/2020 and was taken off of hospice on/around July 2020 per request of resident’s family. The next assessment done on 11/13/2020 is documented as a change in condition following resident’s two recent stays in the hospital. Care level significantly increased to reflect resident now needing assistance during meals, due to eating difficulties, occasional staff time to assist with communication due to being more difficult to understand, , assistance with transfer/escorts/assertive devices, and with special care needs related to skin care, status checks, finger stick by nurse, insulin injections. cont on 9099C(2)... 9099C(2)..Additionally, physician’s report dated 11/18/2020 notes that resident requires a special diet- level 2 mildly thick liquids/ground dysphagia- NEEDS TO BE FED- and requires 2 PERSON ASSIST. Resident charting notes indicate that resident was placed on hospice services on 11/19/2020 . The next assessment was conducted on 1/1/2021 as a periodic assessment with no significant changes in care needs. On 6/28/2021, another periodic assessment was conducted and resident was found to require increased assistance with bathing, hands-on feeding for eating due to resistance and having difficulty in maintaining adequate nutrition, and complete assistance with toileting. Resident remained on hospice through 7/17/2021 when resident passed. Based on information obtained, the department finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility falsified a resident's name Documentation that was completed upon admission to the facility, in October 2019, shows that resident used two last names that were hyphenated. Physician’s report dated 9/23/2019 that was provided to the facility on 10/4/2019 lists the same two last names for resident. Correspondence sent by the facility on 10/18/2019 to resident’s POA refers to resident by both last names. The majority of subsequent paperwork completed by the facility shows both last names. LPA reviewed court conservatorship documents from August 2020 and November 2020 which listed only one last name for resident. Resident’s conservator indicated that both last names were used on hospital and medical records and legal documents, and a court document was revised on/around December 2020/January 2021 to include both last names. Conservator stated she is not aware that resident’s last name was altered to possibly hide resident from family members and resident’s full legal name included the use of two hyphenated last names. Memory Care Director stated that no other resident in Memory Care shared the same first name and staff would have known which resident the caller was asking about based on the first name alone. Based on information obtained, the department finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099C(3)... 9099C(3)... Allegation: Facility chemically restrained resident The department reviewed hospital medical records dating from December 2019 through November 2020 when resident was sent to the emergency room and/or hospitalized for further evaluation. Specifically, medical records from 12/24/2019 reviewed did not mention any medication related concerns. On 2/20/2020, it was determined that there were no injuries from the fall from ground level, and there was no mention of overdose or of any concerns regarding medication. On 3/9/2020, Nancy was admitted to the hospital with main complaint of altered mental status, 11/8/2020, Nancy was admitted with chief complaint of altered mental status after having been sent to the hospital for increased confusion and being less responsive. There was no mention of overdose on drugs or of any other concern regarding medications. On 11/15/2020, resident was admitted with main complaint of altered mental status and was found to have acute kidney injury and hypernatremia with both conditions treated with IV fluids. There is no mention of overdose on drugs or any other concerns with medication. Memory Care Director stated in an interview that the facility got behavioral health involved, through the primary care physician, and they put interventions in place and resident’s medications were "changed around a lot but not to chemically restrain her". Conservator indicated that resident’s medications were reviewed several times by the hospice team, stating, "by no way was she chemically restrained". Based on information obtained, the department finds the allegation to be UNSUBSTANTIATED - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not follow mandated reporter requirements. Hospital medical documentation reviewed by the department dated December 2019- November 2020 indicates that there was no mention of any medication related concerns, including medication overdose. On 12/24/2019, resident was Diagnosed with a urinary tract infection and an altered mental status. On 2/20/2020, Nancy was seen in the emergency room with chief complaint of "stumbling and a mechanical fall". cont on 9099C(4)... 9099C(4)...On 3/9/2020, Nancy was admitted to the hospital with main complaint of altered mental status. Per EMS notes, Nancy was found on the ground and was more altered than her baseline, and her speech was slurred. Hospital determined that Nancy had acute kidney injury, thought to be due to dehydration and was given IV fluid for hydration and was discharged on 3/15/2020 and placed on hospice. On 11/8/2020, Nancy was admitted with chief complaint of altered mental status after having been sent to the hospital for increased confusion and being less responsive. On 11/15/2020, Nancy was admitted due to altered mental status and was found to have acute kidney injury and hypernatremia. Both were treated and resolved with IV fluids. Facility completed and submitted incident reports for each of the incidents. Resident was provided with increased care at the facility from hospice medical staff for periods 3/15/2020 through around July 2020 and 11/19/2020 through 7/17/2021, when resident passed. There was no abuse and/or neglect noted in the hospital medical records that staff should have reported. Based on information obtained, the department finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to Administrator.