complaint·April 13, 2021

Regarding the facility providing banana’s as requested by R1’s physician, a review of medical records revealed that on 7/9/2020, R1 was seen by a physician, whom noted that R1 had low potassium levels and gave an order to feed R1 one banana a day. On 7/15/2020, the physician noted that R1’s potassium was improving and advised to provide two bananas a day. However, interviews revealed that staff were allegedly unaware of this order from the physician. A review of medical records claimed that at that time, the facility was able to send out orders via fax, but they were unable to receive fax messages. Hence, it is likely that the facility missed vital orders pertaining to the care of R1 and were unable to mitigate this challenge at that time. Neither the Facility Progress Notes nor the Medication Administration Record (MAR) noted the order for the banana(s) a day. When R1 was sent to the Emergency Room on 7/30/2020, R1 was diagnosed with hypokalemia (ie. low potassium levels). Based on the investigation, staff noted that there was a change of condition in R1’s appearance and ability to manage their personal grooming and hygiene, however it was not addressed and reported as required. In addition, the facility did not provide bananas to R1 as requested by R1’s physician, and R1 was found to have low potassium levels once evaluated in the Emergency Room on 7/30/2020. This allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided via email for signature, along with appeal rights. On 8/13/2020, the LPA completed the initial virtual visit at 2pm, conducted staff interviews and requested documents. Investigator Hector reviewed medical records on 8/28/2020; interviewed R1’s representatives on 11/05/2020 at 10:19am and 11/06/2020 at 8:58am; interviewed collateral agency staff on 11/05/2020 at 12:20pm; interviewed current staff on 11/6/2020 at 5:04pm, and 11/17/2020 at 11:26am, 11:51am, and 12:17pm; and, interviewed former staff on 11/13/2020 at 12:30pm and on 11/17/2020 at 12:44pm. Regarding the allegation: Facility neglect resulting in resident developing infections It was alleged that due to facility neglect, R1 developed multiple infections, which included a urinary tract infection, an eye infection, and vaginal infection. Interviews and a review of Facility Progress Notes revealed that R1 exhibited a change in condition in June 2020, which included an increase in agitation and confusion. As a result, the facility requested a urinalysis order to rule out a urinary tract infection (UTI) and on 7/3/2020, a urinalysis order was created. In addition, interviews and medical records revealed that R1’s physician was notified of the behavior change and R1 was prescribed one anti-depressant tablet daily. The prescription as increased to two tablets daily on 7/9/2020. Yet, it appeared that the urine sample was not delivered to R1’s physician, hence the physician was unable to rule out if R1 developed a UTI. Per interviews, it was confirmed that a family member of R1 had the urine sample, but they were unable to get the sample to the laboratory. However, the facility did not follow up to ensure that the urine sample was delivered to rule out the UTI. On 7/30/2020, R1 was sent to the Emergency Room for an evaluation of pain. Upon assessment, it was discovered that R1 had a nontraumatic acute kidney injury, dehydration, a urinary tract infection, hyponatremia (low sodium levels) and hypokalemia (low potassium). There was no documentation noting an additional vaginal infection or an eye infection at the time of observation. Interviews revealed that there were multiple reasons as to how R1 could have developed a UTI. Staff denied observing signs and symptoms of dehydration with R1 (such as lethargic, generalized weakness, or dryness of the appearance); comparatively, staff claimed that R1 was drinking fluids and was often seen with or drinking Gatorade. To further investigate the UTI, Investigator Hector interviewed staff regarding R1’s incontinence needs. Interviews revealed that R1 used pull-ups, yet multiple sources stated that R1 would often keep their soiled pull-ups and would attempt to re-use soiled pull-ups rather than obtain a clean pull-up. Interviews revealed inconsistent information as to whether upper management was notified of this behavior, which, had it been communicated, could have resulted in R1 receiving treatment prior to the 7/30/2020 Emergency Room visit. Such behavior of re-using soiled pull-ups could have contributed in the development of the UTI. Regarding the allegation of additional infections, a review of medical notes revealed that staff contacted R1’s primary care physician on 7/31/2020 to report that R1 had ‘greenish discharge’ coming out of their eye, however, there was no additional evidence as to how the facility treated the discharge. In addition, this observation was not documented in R1’s facility progress notes, nor was there any details regarding any necessary follow-up to treat the discharge. Yet, it appears that this change of condition was identified after R1 was sent to the Emergency Room on 7/30/2020. Concurrently, medical records obtained from the Emergency Room visit 7/30/2020 did not reveal an additional vaginal infection outside of the documented UTI. However, R1 was indeed diagnosed with hyponatremia (low sodium levels) and hypokalemia (low potassium). Based on the investigation, there is sufficient evidence to support the claim that due to neglect, R1 developed multiple infections. Whereas the facility attempted address the behavior change, they did not follow through with the urinalysis to identify whether R1 had a UTI. The UTI was discovered when R1 went to the emergency room on 7/30/2020, along with other ailments. This allegation is deemed Substantiated at this time. Regarding the allegation: Facility did not meet resident’s needs It was alleged that R1’s grooming needs were not addressed; and, the facility failed to follow physician orders as R1 was not provided with a banana daily due to low potassium levels. Interviews with members of R1’s family revealed that when the facility allowed visits in June 2020, R1’s hair was not styled and R1’s nails were long. In addition, when R1 was observed in the emergency room on 7/30/2020, it was alleged that R1 was not bathed, fingernails were very long, and R1’s hair was matted. Photos taken and reviewed revealed that R1’s finger and toenails were overgrown. Prior to taking R1 back to the facility on 7/30/2020, R1 was cleaned up and returned to the facility. Interviews with facility staff whom managed R1’s care confirmed that R1 often had a foul smell emitting from their body, would often attempt to re-use soiled diapers, and would refuse showers. Staff described R1’s hygiene as ‘not the best’. A review of R1’s appraisal dated 10/1/2019 stated that R1 was able to independently shower, manage toileting needs, and needed no assistance with personal hygiene. Yet R1’s appraisal dated 7/30/2020 stated that R1 needed assistance with bathing, dressing, hair care, and personal hygiene; and needed assistance with toileting. Staff stated that lack of showering and the behaviors of re-using soiled pull-ups should have been reported to upper management, however documentation nor interviews with upper management confirmed that this transpired. On 8/13/2020, the LPA completed the initial visit at 2pm, conducted interviews and requested documents. Investigator Hector reviewed medical records on 8/28/2020; interviewed a family members on 11/05/2020 at 10:19am and 11/06/2020 at 8:58am; interviewed a collateral agency staff member on 11/05/2020 at 12:20pm; interviewed current staff on 11/6/2020 at 5:04pm, and 11/17/2020 at 11:26am, 11:51am, and 12:17pm; and, interviewed former staff on 11/13/2020 at 12:30pm and on 11/17/2020 at 12:44pm. Regarding the allegation: Facility did not notify representative of resident's decline in health It was alleged that R1’s representatives were unaware of R1’s decline in health. Records review and interviews revealed that in June 2020, the facility notified R1’s representative of R1’s increased confusion, mood shift and change in condition. As a result, the facility requested a urinalysis and received an anti-depressant to address R1’s behaviors. In addition, documentation revealed that on 7/29/2020 a discussion was had with R1’s representatives about moving R1 to the memory care unit due to R1’s increased confusion. Interviews with R1’s representatives confirmed that whereas they were unaware of R1’s general grooming and hygiene concerns, it was confirmed that the facility noticed a change in mood and sought to address potential behavioral issues. Staff interviews revealed inconsistent information as to whether upper management was notified of R1’s behavior of re-using soiled pull-ups and refusing showers; which, had it been communicated, could have resulted in the family being notified of R1's other behavioral changes, along with R1 receiving treatment prior to the 7/30/2020 Emergency Room visit. However, management was in active discussions with R1’s representative regarding moving R1 to the memory care unit for additional care and supervision. Based on the information obtained, there is insufficient information to support the claim that the facility did not notify representative of resident’s decline in health. The facility notified R1's representatives with the change of condition and potential for memory care placement yet were unaware of R1’s undiagnosed infections and other behavioral challenges until R1 was sent to the Emergency Room on 7/30/2020. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued via email for signature.