complaint·August 10, 2022

On 5/11/2022 LPA Avetisyan requested copy of R1’s death Certificate from Option One Congregate living and Tri Valley Hospice. Copies of the Death certificate were received on 5/12/2022 and 5/11/2022. Upon review, both copies of the death certificate documented R1’s cause of death to be Advanced Parkinson’s without any other contributing diagnosis. Based on the information obtained, there is insufficient evidence to support the allegation, therefore the allegation of Question death is deemed Unsubstantiated at this time. Exit interview conducted, copy of report and appeal rights issued. On 4/13/2022 Licensing Program Analyst (LPA) Yelena Avetisyan emailed subpoena for records to Tri Valley Hospice Care, Inc. Records were received on 4/22/2022. On 5/11/2022 a subsequent complaint visit was conducted by Licensing Program Analyst (LPA) Yelena Avetisyan. On that day LPA Avetisyan conducted re-review of R1’s facility records and interviewed staff who were working at the facility when the 9/11/2021 and 10/9/2021 injuries occurred. Records reviewed and interviews conducted revealed the following: In regard to the allegation of: Resident 1 (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care: It was reported that on 9/11/2021 R1 was taken to Henry Mayo Newhall emergency room with a dislocated left shoulder and staff were not aware how R1 sustained the injury. On 10/19/2021 LPA Panushkina communicated with R1’s family who reported that upon their return from the emergency room staff reported to them that R1 started feeling pain after dinner, and hospice was called the next morning because of the pain worsening. While conducting review of facility records LPA Avetisyan observed the following documented on the licensees Resident Care Notes: 9/10/2021 at 22:15 pm staff requested assistance from the med-tech because R1 was “grimacing when touching left shoulder”. Upon med-tech documented slight swelling on L side. Staff noted “informed the health director, also to contact hospice and monitor shoulder and pain” On 9/11/2021 at 23:50 am Med-tech documented R1 “in a lot of pain L shoulder hurting to slightest touch. Called Hospice will send a nurse in the morning” per staff notes the hospice instructed to administer morphine as PRN. However, the hospice communication log documented the hospice agency receiving a call to see R1 due to severe pain and swelling to the left shoulder. Caregiver reported R1 “is crying, grimacing, pulling back” Hospice communication log also documents caregiver reported giving R1 2 doses of morphine for severe pain. The call was documented on the communication log on 9/11/2021 at 09:30 am. Hospice staff arrived at the facility approximately 9:15 am on 9/11/2021 and transported to the hospital by Power of Attorney at approximately 10:00 am. However, hospital records document resident being admitted to the Emergency room 14:38 pm. Additional information obtained during the course of the investigation revealed that facility and hospice records documented R1 being a fall risk however licensee did not have a fall risk plan in place. Staff are asked to call Hospice agency first for any incident that occurs with residents regardless if the reason for the call is related to the terminal diagnosis. The licensee/administrator failed to follow reporting requirements related to this incident. In regard to the allegation of: Due to staff neglect Resident 1 (R1) sustained severe facial injuries it was reported that on 10/9/2021 R1 was transported to Henry Mayo Newhall ER and diagnosed with Facial injuries (laceration of lip, fracture of nasal bones). When interviewed R1’s family stated that the facility staff called them and reported that staff were pushing R1 in a wheelchair, R1 put her feet down on the floor, launched forward and fell on her face. R1’s family reported that resident was very weak, and they do not believe R1 would be able to launch herself forward. Review of Tri Valley hospice POC/IDG, review dated 10/9/2021 documents records prior to the incident for R1’s mobility as Bed-Bound/Chair-bed transfer, dependent on 6/6 ADL’s, requires repositioning ever 2 hours. 10/5/2021 Home Aid (HA) visit documents R1 carefully transferred to the shower. While conducting review of Resident Care Notes LPA did not observe documentation regarding the incidents. 5/11/2022 Staff interviews revealed R1 was being pushed to the dining room by Staff 1 (S1). Staff did not observe the incident however reported being called for assistance, hearing R1 loudly screaming for help and observing R1 bleeding severely. According to staff interviewed they did not observe footrests on the wheelchair. Staff interviewed also reported questioning S1’s explanation of how the accident occurred and questioned the speed of the wheelchair. According to Staff R1 had a tendency to put her foot down from wheelchair and would be able to walk with 2 staff holding onto her but not sure if R1 could stand on her own. Investigator Kujuwa and LPA Avetisyan attempted to conduct interview with S1 but were unable to do so. Staff # 4 also informed the LPA that incident details were documented on the Crossover report. On 5/11/2022 administrator Cyntia Drachenberg informed the LPA that Crossover reports are only kept for a month. LPA was also informed that information regarding both of the incidents were documented in the company's internal reports which would not be released to the Department. Based on the information obtained there is sufficient evidence to support the allegations, therefore the allegations of Neglect/Lack of Care and Supervisor Resident 1 (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care and Due to staff neglect Resident 1 (R1) sustained severe facial injuries are deemed Substantiated. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.