Incident investigation·May 12, 2023

Licensing Program Analyst (LPA) KaSandra Lopez conducted a Case Management - Incident visit to issue final findings and citations related to the initial Case Management - Incident visit conducted on 02/25/2020. LPA Lopez met with Administrator Joey Alvarado and the reason for visit was explained. On 02/25/2020, from 10:25 a.m. to 12:15 p.m., LPA D. Perera conducted an unannounced Case Management - Incident visit to the above facility. The purpose of the visit was to follow up on a death report submitted to the Department on 02/21/2020. LPA Perera met with Business Office Manager Michelle Greenberg and Health and Wellness Director Vivian Reyes. The death report received reflected that Resident #1 (R1) was transported to the hospital on 01/30/2020 after sustaining a fall on the sidewalk outside the facility. R1 died at Los Robles Hospital on 02/18/2020 after being taken off the ventilator on 02/17/2020. During the facility visit, LPA Perera conducted a file review at 10:43 a.m. and obtained pertinent documentation relating to the incident. LPA also conducted a brief interview with Health and Wellness Director to obtain additional information at 10:59 a.m. LPA determined that further investigation was needed, and the case was referred to Community Care Licensing Investigation's Branch (IB) Investigator Joseph Balarie. Investigator Balarie conducted an interview with Troy Byington, Facility Executive Director, on 03/10/2020 at approximately 9:40 a.m., and with facility staff and residents from approximately 11:00 a.m. to 12:10 p.m.; on 03/11/2020 at approximately 10:00 a.m. with R1’s conservator; on 04/10/2020 from approximately 1:10 p.m. to 2:00 p.m. with facility staff; and on 04/14/2020 at approximately 10:00 a.m. with Los Robles Regional Medical Center Doctor Elise L. Bukont. Facility records and medical records were also obtained and reviewed. Report continued on LIC 809-C. R1’s Physician Report, dated 03/14/2019, stated that R1 should be escorted by staff due to cognitive impairment. R1 was diagnosed with Dementia, the loss of intellectual functioning “such as thinking, remembering, reasoning, exercising judgement and decision making”. According to R1’s Physician Report, R1 should not have been allowed to leave the facility unattended. R1 was also prescribed Plavix, a blood thinner which reduces the ability for blood to clot causing blood to leak out and take longer to clot. The Unusual Incident/Injury Report stated, on 01/30/2020, at approximately 2:30 p.m., a caregiver notified facility staff that R1 was outside the building. Two caregivers saw R1 walking on the sidewalk, 0.2 miles from the facility and were about to escort R1 back to the facility. Before the caregivers could reach R1, R1 tried to turn, lost balance and fell on face on the sidewalk. R1 had blood coming out of nose and an abrasion on left knuckle. R1 was alert and complained of pain on nose. R1 was brought to the Emergency Department. R1 was noted to have altered mental status and was intubated for airway protection. R1 was subsequently admitted to the ICU. R1 was diagnosed with having a subarachnoid hemorrhage (bleeding within the subarachnoid space, which is the area between the brain and the tissue covering the brain), and a C2 cord contusion. Medical notes stated that it is unclear if R1 had a bleed and then passed out or if the fall resulted in R1’s head injury. There is minimal external trauma on examination and clinical suspicion is that R1 had a bleed then fell. R1 was intubated and maintained on supportive care. R1’s family elected to initiate comfort care only and admitted R1 to inpatient hospice on 02/17/2020. R1 was compassionately extubated and passed away 02/18/2020 at 3:10 p.m. R1’s Certificate of Death indicated R1 died from complications of craniocervical trauma and left rib fractures. The investigation revealed that facility staff were unaware R1 left the facility unattended on 01/30/2020. Furthermore, the Facility Executive Director (former), Troy Byington, was unaware of R1’s physician report that indicated R1 was not allowed to leave the facility unattended. On 03/10/2020, during a visit to the facility, Investigator Balarie observed no staff near the front door. Facility staff were busy with the duties of the day and seemed to not notice who entered and left the facility including the sign-out sheet. Based on information and documentation obtained during the investigation, the Department determined that lack of care and supervision by the facility led to the fall and hospitalization of R1. Report continued on LIC 809-C. A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.