complaint·August 17, 2022

On 04/11/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that the facility staff failed to obtain timely medical care for Resident #1 (R1). It was reported that on 04/08/2022 the overnight (NOC) shift witnessed R1 with a nosebleed and a bruise to left eye, yet R1 was not transported to a medical facility until 1:00 p.m. later that day. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Olivia Spindola. On 04/12/2022, between 10:15 a.m. and 2:15 p.m., LPA Campos conducted the initial 10-day complaint visit. The LPA met with the Administrator Eileen Esquivel and explained the reason for the visit. During the visit there were ten (10) staff and thirteen (13) residents present. The LPA reviewed records and obtained pertinent copies of documents at 11:00 a.m. and 1:40 p.m. From 10:25 a.m. to 12:10 p.m., the LPA conducted a physical plant tour with the Administrator and interviewed staff. The Administrator was notified that the complaint was referred to the Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Olivia Spindola. On 04/16/2022, LPAs Campos and Ashley Smith conducted an unannounced subsequent complaint visit. The LPAs met with Business Office Manager Megan Cordova and explained the reason for the visit. During the visit, the LPAs conducted a physical plant tour at 1:20 p.m., conducted a file review at 11:00 a.m. and interviewed staff from 11:50 a.m. to 3:49 p.m. The LPAs noted further investigation was required. Investigator Spindola conducted interviews with the facility Health Services Director on 05/03/2022, at approximately 11:00 a.m.; with the facility Executive Director/Administrator at approximately 12:10 p.m.; with facility caregiver at approximately 12:45 p.m.; with the facility Environmental Services Director at approximately 1:30 p.m.; with a facility resident at approximately 1:50 p.m.; on 05/12/2022 and 06/28/2022 left voice messages for R1’s representative; with R1’s representative on 07/06/2022 at 9:00 a.m.; with facility staff on 07/07/2022 from approximately 12:00 p.m. to 12:30 p.m.; and with facility staff on 07/08/2022 from approximately 10:30 a.m. to 11:30 a.m. Additionally, Investigator Spindola reviewed copies of R1’s facility records, medical records and photos of R1’s injuries. Continued on LIC 9099-C R1 was admitted to the facility on 03/23/2022. According to the Physician Report dated 03/22/2022, R1’s primary diagnoses included Dementia and listed R1 as non-ambulatory. R1’s mental condition was noted as confused, disoriented, with inappropriate and aggressive behavior. The report listed no wandering or sundowning behavior. The facility assessment, dated 03/23/2022, noted R1 “had no mobility issues, no known sleep issues, and no known fall risk”. The assessment noted R1 was “mobile and there were no ambulation concerns according to the physician’s assessment and personal assessment”. The investigation revealed that on 04/08/2022, R1 sustained an unwitnessed fall. Sometime after 2:00 a.m., the overnight (NOC shift) facility caregivers witnessed R1 with a nosebleed and gave R1 an ice pack. When the caregivers asked R1 how R1 injured their face, R1 told them they could not remember. At 4:00 a.m., the caregivers noticed R1’s eye had a small bruise. Staff #1 (S1) then sent a text message to the facility Health Services Director and Administrator. Later that day, R1 was taken to West Hills Hospital and diagnosed with fractures to the nose and left eye orbit. Based on the fact that the fall was unforeseen, R1 could not remember how they sustained the facial injuries, R1 was no considered a fall risk and no witnesses observed the fall, the allegation “Due to facility neglect/lack of supervision, Resident #1 (R1) sustained facial fractures while in care” is deemed Unsubstantiated at this time. Allegation: Staff are getting into trouble by management for calling 911 It was alleged that when staff felt that they needed to call 9-1-1 for an emergency, management threatens to fire them. Interviews with staff revealed that they have not been directed or discouraged from calling 9-1-1; rather, staff are encouraged whenever they determine residents are in need of elevated medical assistance to inform the Administrator and or Health Services Director to ensure that all parties are appropriately notified. Interviews further revealed that if there is an emergency situation, staff should call 9-1-1 before informing the administrator or health services director, a delay in calling the administrator first could cause a resident their life. The administrator and health services director were reminded that staff are essential in assessing the resident appropriately and taking on the decision to call 9-1-1 during emergencies. The facility has taken steps to re-train on 9-1-1 protocols. This investigation did not reveal any evidence of “staff getting in trouble by management for calling 9-1-1”; therefore, this allegation is deemed Unsubstantiated at this time. On 04/11/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that the facility staff failed to obtain timely medical care for Resident #1 (R1). It was reported that on 04/08/2022 the overnight (NOC) shift witnessed R1 with a nosebleed and a bruise to left eye, yet R1 was not transported to a medical facility until 1:00 p.m. later that day. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Olivia Spindola. On 04/12/2022, between 10:15 a.m. and 2:15 p.m., LPA Campos conducted the initial 10-day complaint visit. The LPA met with the Administrator Eileen Esquivel and explained the reason for the visit. During the visit there were ten (10) staff and thirteen (13) residents present. The LPA reviewed records and obtained pertinent copies of documents at 11:00 a.m. and 1:40 p.m. From 10:25 a.m. to 12:10 p.m., the LPA conducted a physical plant tour with the Administrator and interviewed staff. The Administrator was notified that the complaint was referred to the Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Olivia Spindola. On 04/16/2022, LPAs Campos and Ashley Smith conducted an unannounced subsequent complaint visit. The LPAs met with Business Office Manager Megan Cordova and explained the reason for the visit. During the visit, the LPAs conducted a physical plant tour at 1:20 p.m., conducted a file review at 11:00 a.m. and interviewed staff from 11:50 a.m. to 3:49 p.m. The LPAs noted further investigation was required. Investigator Spindola conducted interviews with the facility Health Services Director on 05/03/2022, at approximately 11:00 a.m.; with the facility Executive Director/Administrator at approximately 12:10 p.m.; with facility caregiver at approximately 12:45 p.m.; with the facility Environmental Services Director at approximately 1:30 p.m.; with a facility resident at approximately 1:50 p.m.; on 05/12/2022 and 06/28/2022 left voice messages for R1’s representative; with R1’s representative on 07/06/2022 at 9:00 a.m.; with facility staff on 07/07/2022 from approximately 12:00 p.m. to 12:30 p.m.; and with facility staff on 07/08/2022 from approximately 10:30 a.m. to 11:30 a.m. Additionally, Investigator Spindola reviewed copies of R1’s facility records, medical records and photos of R1’s injuries. Continued on LIC 9099-C The investigation revealed that on 04/08/2022, R1 sustained an unwitnessed fall. Sometime after 2:00 a.m., the overnight (NOC shift) facility caregivers witnessed R1 with a nosebleed and gave R1 an ice pack. When the caregivers asked R1 how R1 injured their face, R1 told them they could not remember. At 4:00 a.m., the caregivers noticed R1’s eye had a small bruise. Staff #1 (S1) immediately left messages via text for the Health Services Director and the Administrator informing them of R1’s injuries and requested approval to send R1 to the hospital; however, they did not respond to the text messages. Between the hours of 7:00 a.m. and 12:00 p.m., caregivers informed the Health Services Director and the Administrator of R1’s serious facial injuries and the need to obtain immediate medical care. At approximately 1:00 p.m., the Health Services Director notified R1’s representative of R1’s need of medical care. R1’s representative agreed to come to the facility and transport R1 to the hospital for medical care. R1’s representative took R1 to West Hills Hospital where R1 was diagnosed with fractures to the nose and left eye orbit. The Administrator and the Health Services Director did not take action to have R1 transported to a medical facility for more than 8 hours, in spite of several staff informing them of R1’s need for medical care. Therefore, the allegation “Neglect/Lack of Supervision - Facility staff failed to obtain timely medical care for Resident #1 (R1)” is deemed Substantiated at this time. Allegation A supervisor was not available for guidance It was alleged that a supervisor was not available for guidance when staff attempted to contact the supervisors on 4/8/2022 to inform them that a resident #1 (R1) was exhibiting a serious looking injury on their face. Although the allegation is that a supervisor was not available, they were actually asking for an administrator (ED) and or health services director (HSD). It was alleged that on 04/08/2022 the ED and HSD failed to get back to facility staff after staff attempted to contact them at approximately 1:00 a.m. when R1 was observed exiting their bedroom with a bloody nose. Interviews revealed that rather than calling the ED and or the HSD, staff only sent a text message at approximately 4:00 a.m., approximately 45 minutes after R1’s injuries were observed to have worsened. Staff interviews revealed that staff felt that the ED and or HSD are available, as needed; and, that the directive is not only to text but to call when there is an emergency or staff need guidance. Interviews with the ED and HSD revealed that staff did not call but only sent a text. However, the ED and HSD failed to respond and no other attempts to seek guidance by staff or call 9-1-1 were attempted therefore R1 was neglected. The HSD was again informed in the morning at approximately 7:00 a.m. that R1 needed assessing. The HSD stated that they would assess R1 upon their arrival, but never did and instead left to take another resident to an appointment while R1 lay in bed. It was not until the HSD’s return to the facility that R1 was assessed. Based on the fact that the staff did not exhaust all options to contact supervisors regarding R1 upon the discovery of their injuries and supervisors did not return calls or texts timely, the allegation “a supervisor was not available for guidance” is deemed Substantiated at this time. Allegation Staff did not notify authorized representative of resident injury. On 04/11/2022, the Department received a complaint regarding allegations that staff did not notify authorized representative of resident injury. The investigation revealed that on 04/08/2022, R1 sustained an unwitnessed fall. Sometime after 2:00 a.m., the overnight (NOC shift) facility caregivers witnessed R1 with a nosebleed and gave R1 an ice pack. At 4:00 a.m., the caregivers noticed R1’s eye had a small bruise. Staff #1 (S1) immediately left messages via text for the Health Services Director and the Administrator informing them of R1’s injuries and requested approval to send R1 to the hospital; however, they did not respond to the text messages. Between the hours of 7:00 a.m. and 12:00 p.m., caregivers informed the Health Services Director and the Administrator of R1’s serious facial injuries and the need to obtain immediate medical care. Whereas staff believed that the Administrator would contact R1’s representative immediately it was not until approximately 1:00 p.m., that the Health Services Director notified R1’s representative of R1’s need of medical care. R1’s representative agreed to come to the facility and transport R1 to the hospital for medical care and R1’s representative took R1 to West Hills Hospital. Continued on LIC 9099-C The Administrator and the Health Services Director did not act to immediately to inform R1’s authorized representative, in spite of several staff informing them of R1’s injuries in the early hours of the day. Therefore, the allegation that “Staff did not notify authorized representative of resident injury” is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Administrator Eileen Esquivel was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.