complaint·August 29, 2024

continued from 9099 On 02/27/2024, at approximately 9:30 a.m., Investigator Zertuche conducted interviews with R1’s resident representative; on 03/28/2024, from approximately 8:30 a.m. to 10:00 a.m., with the Residential Care Director and staff; on 04/24/2024, at approximately 12:30 p.m., with R1’s resident representative; and on 05/15/2024, at approximately 4:30 p.m., with R1’s Primary Care Physician. In addition, the investigator reviewed West Hills Hospital medical records, and other facility file documents related to R1. According to the facility file documents reviewed, R1 was admitted to the facility on 09/08/2020. R1’s physician's report, dated 08/03/2023, showed a diagnosis of cerebral infarction (stroke) as well as seizure disorder and depression. R1 was listed as non-ambulatory due to physical condition. A physician's report, dated 08/14/2020, was similar except that R1 had the capacity for self-care such as bathing and grooming self. There were two incident reports included, dated 11/10/2021, where R1 sustained a fall and injured their hand. The second incident occurred on 07/30/2023 where R1 was found on the floor after an unobserved fall sustaining facial swelling and skin tears to chin. Facility notes indicated R1 had various additional unwitnessed falls on 05/10/2021, 02/25/2022 (returned from ER with cast- no further information), 09/06/2022, 12/22/2022, 01/24/2023, 02/08/2023, 03/28/2023, 04/04/2023, 06/15/2023, 07/01/2023. According to the facility's service agreement, they are to regularly assess residents to assure they are receiving care and services appropriate to their needs. There were several assessments included with the documentation from October 2020 to February 2024 documenting R1 as a fall risk and is to be checked during each shift with the last assessment stating, "fall risk - safety room checks with increased frequency due to fall risk." There was a fall risk assessment in R1’s file but it was blank. Due to the numerous falls, a private caregiver was provided by R1’s resident representatives. A review of the West Hills Hospital medical records revealed there were numerous visits to the hospital for R1 due to unwitnessed falls where R1 sustained several injuries to the head, arms, legs, and chin along with fractures to the ribs and wrist occurring between June 2021 and July 2023. There were also a couple of visits regarding seizures, altered mental status and weakness. Many of the visit notes showed R1 was unable to communicate listing R1 as being confused and several notes indicated there was no report of abuse or neglect. Continued from 9099-C On the allegation “Neglect/Lack of Supervision – Resident #1 (R1) suffered multiple falls resulting in injuries” – Medical and facility records show that R1 sustained at least 12 falls over a two-year period, mostly unwitnessed, sustaining numerous injuries. Most of the falls were sustained in the last six months where R1 fell at least seven times prior to going on hospice care. Staff members reported R1 was independent but had increased supervision due to the falls. However, R1 continued to fall. R1’s family reported the facility's care was insufficient, so they hired a private caregiver after the last fall stating staff members rarely checked on R1 when they were visiting. Based on the evidence of at least seven falls in a short time, it appears as if R1 required a higher level of care that the facility did not provide, resulting in sufficient evidence to substantiate neglect/lack of supervision. Therefore, the allegation is deemed substantiated at this time. It was additionally reported that "Staff did not ensure that resident's medication(s) were ordered in a timely manner" as it was alleged that R1 did not get medication(s) administered on 12/30/2023 due to medications not being ordered. Interviews conducted and records review revealed the following medications were not delivered in time for R1's PM dosing: Amlodipine 2.5mg, Docusate Sodium 100 mg, Losartan 25 mg, Melatonin 5 mg, Metroprolol Tartrate 50 mg and Mirtazapine 15 mg. LPA's Interview with Kelly Penrose, LVN Director of Resident Care Services further revealed that medications are typically ordered seven (7) days out , but staff could not confirm why the medication did not arrive as scheduled at this time , Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine the allegations occurred. Therefore, the allegations that “Staff did not ensure that resident's medication(s) were ordered in a timely manner” has been deemed Substantiated at this time. It was reported that "Staff did not reassess resident as necessary" as it was alleged that R1 was never reassessed after having multiple falls. LPA's records review of daily nurse logs revealed R1 sustained eight (8) falls on the following dates: 05/10/2021, 11/10/2021, 09/06/2022, 01/04/2023, 01/24/2023, 04/04/2023, 06/15/2023, and 07/11/2023. LPA's records review of reappraisals revealed that re-appraisals were only conducted two (2) times after R1 fell on 09/06/2022 and 04/04/2023. Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine the allegations occurred. Therefore, the allegations that “Staff did not reassess resident as necessary" has been deemed Substantiated at this time. Continued from 9099-C A $500 immediate civil penalty is assessed today. The Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued It was reported that "Staff did not provide assistance to resident in a timely manner" as it was alleged that staff were not responding to R1's call button in a timely manner and did not provide oxygen treatment as prescribed. LPA's interviews conducted with seven (7) residents revealed that all (7) have typically had to wait approx. 5 to 10 mins when requesting assistance from staff. Interviews with residents further revealed they did not express any potential or immediate concerns that staff would not provide assistance in a timely manner. Interviews conducted with ten (10) staff revealed that when residents call for assistance they typically attempt to service resident within five (5) minutes. If it ever gets to a wait time of ten (10 ) mins there are alarms located at the concierge desk and the medication room that signals when a resident has waited (10) minutes and staff are alerted to get to that resident right away. In addition all (10) staff have never observed any resident not receive their oxygen treatment as prescribed. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not provide assistance to resident in a timely manner"” is deemed Unsubstantiated at this time. It was reported that "Facility charged resident for services not rendered" as it was alleged that R1 was signed up for "Enhanced Personal Care II" , but services were not provided. Interviews conducted and records review reflected that a reassessment was conducted on 08/03/2023 and facility staff notified the family / responsible party of R1 to sign R1 up for "Enhanced Personal Care II", which included bathing or transfer assistance by (2) staff member, feeding assistance by one staff member, assistance with changing continence products and any service included in "Enhanced Personal Care I (Hands-on assistance with showering four or more times per week, transfer assistance by one staff member, assistance with changing continence products and any service included in basic personal care). The Enhanced Personal Care II services began on approx. 08/30/2023. Interviews conducted with ten (10) staff revealed that part of their protocol is to check on each resident in their assignment at the start of their shift. For the morning shift, this involves aiding with brushing their teeth, toileting, getting dressed then assist to dining room if the resident would like to eat. Throughout the day residents are checked at least every 2 hours and upon request. Residents are typically showered at least twice a week, but depending on their care plan some residents may also get showered every day. continued from 9099-C Further interviews conducted with the (10) staff confirmed they have never observed a resident who required incontinent care, showering assistance, feeding assistance, two-person assistance, or checks every two hours not receiving those services. Interviews with private caregivers who began serving R1 in August 2023 revealed that they have never seen facility staff fail to provide showering assistance, feeding assistance, two-person assistance, or checks every two hours. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Facility charged resident for services not rendered” is deemed Unsubstantiated at this time. It was reported that "Staff did not ensure that Residents were supplied with a call pendant while in care," as it was alleged that R1 did not have a call pendant due to a shortage of items. Interviews conducted and records review revealed R1 received a new pendant on 09/15/2020. Interviews conducted with ten(10) staff revealed that all (10) have always observed R1 with a pendant. Furthermore each staff interviewed do not recall a time when it was mentioned to family, residents or other staff that there was a national pendant shortage. In addition, LPAs interview with the private caregivers revealed they have always observed R1 to be in possession of a pendant. LPA's interview with seven (7) residents revealed that one (1) out of seven (7) residents uses a pendant. In the event of an emergency, the other six (6) residents stated they would use one of the multiple pull cords in the room. In addition all (7) residents interviewed do not recall of hearing about a national pendant shortage from staff and all did not express any potential or immediate concerns of not being able to obtain a pendant upon request. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not ensure that Residents were supplied with a call pendant while in care” is deemed Unsubstantiated at this time. Continued from 9099-C It was reported that “Staff do not assist with residents' incontinence needs as necessary” as it was alleged that R1 is not being changed in a timely manner. Interviews conducted with ten (10) staff revealed that residents are checked before the start of every shift and at least every two (2) hours throughout their shift. Eight (8) out of the (10) staff interviewed stated they have never observed a resident to be heavily soiled. Two (2) out of the (10) staff stated that they have observed some residents heavily soiled, but it is unclear if it was due to being soiled for a long time or if the resident had a heavy bowel / bladder moment. Interviews conducted with private caregivers revealed they have not never observed R1 to be severely soiled due to not being changed in a timely manner, however they have observed R1 heavily soiled due to a heavy bladder movement. Furthermore, the private caregiver did not express any potential or immediate concerns that facility staff would not provide incontinence service in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not assist with residents' incontinence needs as necessary” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.