complaint·August 14, 2019

learned that R1 was admitted to Vitas Hospice on 6/20/18 due to having a terminally ill disease. Based on interview of the Administrator, LPA was told that facility has been following physician's orders and hospice notes in order to meet he needs of the R1. LPA was unable to interview R1 as R1 declined to speak with LPA. After reviewing the file of R1, LPA did not observe any concerns of facility not following physician's orders. There is insufficient evidence to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Administrator. resident bedrooms located on the Basement floor of the D and E sections of the building and tested the call light buttons. LPA obtained a copy of the contract from Safety Centric regarding installation of the new call light system along with the "Call Light Safety Log" performed by staff. The investigation revealed the following; Allegation: Staff failed to keep residents call button in operable condition. Based on interviews conducted of management, the statements obtained did not corroborate with this allegation. During a walk through of resident rooms located on the Basement floor of the D and E sections of the building and observed the following concerns; -At 9:57AM, Assistant Administrator tested the call light button in Room #153E with LPA present and the call light button was observed to be inoperable as there was no light or sound on the intercom and no response from staff. -At 10:05AM, Assistant Administrator tested the call light button in Room #155E with LPA present and the call light button was observed to be inoperable as there was no light or sound on the intercom and no response from staff. -At 10:07AM, Assistant Administrator tested the call light button in Room #159E with LPA present and the call light button was observed to be inoperable as there was no light or sound on the intercom and no response from staff. -At 10:09AM, Assistant Administrator tested the call light button in Room #157E with LPA present and the call light button was observed to be inoperable as there was no light or sound on the intercom and no response from staff. -At 10:11AM, Assistant Administrator tested the call light button in Room #156E with LPA present and the call light button was observed to be inoperable as there was no light or sound on the intercom and no response from staff. -At 10:13AM, Assistant Administrator tested the call light button in Room #158E with LPA present and the call light button was observed to be inoperable as there was no light or sound on the intercom and no response from staff. -At 10:15AM, Assistant Administrator tested the call light button in Room #160E with LPA present and the call light button was observed to be inoperable as there was no light or sound on the intercom and no response from staff. LPA learned that the intercom has been in disrepair since 8/13/19. Based on LPAs observations, the only resident room located in the E section of building (basement level) with a working call light was Room #161E. Currently the facility is in the process of updating all resident rooms with a new call light and intercom through Safety Centric Security Installation (SCSI). After speaking with the Technician and his Supervisor from SCSI, LPA was told that although the facility is upgrading to a new call light system, nothing was disconnected on the existing call light system or wiring in resident rooms. Supervisor / Ron Gates stated that the new call light equipment is independent from the exiting system and has a new wiring and a new brain. LPA was also told that the existing call light system is removed upon installation of the new call light system in each resident bedroom so that residents may continue to alert staff if needed without interruption. Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.