complaint·November 5, 2021

Allegation #1, that "Resident suffered multiple falls while in care" has been substantiated based on the records reviewed and interviews conducted. A review of R1’s Home Health Agency’s (HHA’s) communication log with the facility indicates that on 10/31/20 at 5:24pm R1’s nurse was informed “Per facility PCG report: patient fell from the bed while was trying to get up unassisted.” A review of the admission records for R1 at Northridge Hospital Medical Center on 11/5/21 indicate that a X-ray of the chest revealed “multiple left-sided rib fractures, which are new since prior study dated June 10, 2020.” However, both staff interviewed by LPA on 11/16/20 denied that R1 had experienced any recent falls, and the only incident report ever submitted by the facility for R1 was when they were hospitalized on 11/5/20 for “low intake” and “low reading results from blood pressure.” Allegation #2, that “Resident is malnourished” has been substantiated based on the records reviewed and interviews conducted. On 11/16/20 LPA interviewed the facility’s Wellness Director telephonically and they stated that R1 had been recently hospitalized for “general weakness” and confirmed that they were “always refusing meals,” but denied that R1 had experienced any sort of "rapid or concerning weight loss.” LPA was informed by W1 though that on 11/5/20 W1 was informed by R1’s Home Health nurse that R1 appeared malnourished. A review of R1’s HHA’s communication log with the facility for 11/5/20 at 11:08 am shows that “per facility staff report: patient is weak, refused to eat since yesterday...” A review of the facility’s food intake record for R1 for November 2020 shows that significant percentages of food and fluid intake were still being recorded from 11/1/20-11/4/20, however, the Northridge Medical Center admission record from 11/5/20 indicates that “In the emergency department the patient was found to be significantly dehydrated with acute renal failure and he was admitted for further evaluation and treatment.” R1 was given IV fluids, antibiotics to treat aspiration pneumonia, and discharged to a Skilled Nursing Facility. Report reviewed, signed and delivered. Exit interview conducted