complaint·March 1, 2024

The hospital records were subpoenaed and reviewed by IB investigator Heidy Bendana. On 11/30/22, IB Investigator Bendana conducted a complaint investigation visit to the facility at which time the investigator reviewed facility files and interviewed five (5) staff and three (3) residents. Regarding the allegation: Staff did not seek timely medical attention for a resident in care. It’s being alleged that Resident 1 (R1) had experienced weakness, problems breathing and urinary discomfort for an unspecified period of time. Staff had knowledge of R1’s condition and did not seek medical attention. During the IB investigation, information was gathered through facility files, including resident records, and medical records. Interviews were conducted with potential witnesses and staff. During interviews, it was discovered that R1 had complained of stomach and abdominal pain for an unspecified time. R1’s urine output was very little. R1 was vomiting and was running a fever. Four (4) out of the thirty-three (33) staff members confirmed R1 was vomiting and had low output. One (1) staff member stated R1 was declining for about a week. Two (2) staff members stated R1 reported they were not feeling well and were in pain. The Administrator confirmed they were aware of the medical conditions and health history of R1. The Administrator also admitted that a staff member reported about R1 experiencing stomach pain and having minimal urine output. The Administrator stated they did not know the length of time R1 had been in pain. The Administrator then called home health who advised to send R1 to the hospital. One (1) of the witnesses interviewed by IB indicated that based on R1’s health conditions and on low or little urine output, the issue should have been immediately addressed by a skilled professional or staff. If not addressed, the issue could lead to a urinary tract infection which can cause sepsis or a fever and also could cause low blood pressure. The facility documents notated the resident complained of pain and discomfort. Based on interviews and record review, there is a sufficient information and/or evidence to support the allegation. Therefore, the allegation is substantiated . Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiency was observed and cited during the visit. See LIC 9099-D.