Complaint·February 7, 2024

After the fall R1 obtained rehabilitation at an outside facility and returned to the transitional memory care in November of 2023. R1 had two falls one on 1/15 and one on 1/24/24. Document review revealed the following: Physician’s report dated 9/6/23 notes R1 is ambulatory. Resident assessment dated 12/4/23 notes special concern – care level description fall concern. Needs and Services Plan dated 11/21/23 notes “resident will ambulate with walker”, however it does not note that the resident is at risk of falls. Incident report dated 2/2/24 to report incident on 1/15/24 notes R1 “glided on the floor hitting the knees” and does not note information on action taken or planned to prevent future falls. Incident report dated 2/2/24 to report incident on 1/24/24 notes care staff found R1 siting on the floor and was picked up. No action taken or follow ups are noted. Hospice plan of care dated 2/7/24 notes R1 has had repeated falls. Hospice plan was created on 12/13/23. One of the goals created was to prevent falls and minimize injury. Facility staff failed to follow Hospice care plan to prevent falls and to update or provide a plan of care to be followed by staff to prevent falls for R1. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . Regarding allegation: Staff did not follow protocol regarding resident falling and Facility staff did not report resident's fall to the proper agencies. It is alleged staff did not follow protocol of assessing the resident, calling hospice, and picked up resident and staff decided not to report the fall to reporting parties. Interviews with residents revealed 6 out of 8 residents stated staff are helpful and will call 911 for them in case of a fall. 2 out of residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed that staff are to evaluate the resident, notify supervisor, call 911 or hospice services, notify family, and notify community care licensing (CCLD)/ Local Ombudsman (LTCO). Per Memory Care Director, for residents under hospice they are to call hospice agency and speak with a nurse who will provide instructions for care of a resident that has fallen. Interview with hospice agency revealed that facility did not notify them of the falls R1 had on 1/15/24 and 1/24/24 and only came to know of the incidents through a third party during the visits. Incident occurred on 1/15/24 does not note any action taken by the facility. Incident occurred on 1/24/24 notes “sitter said not to call 911 and was assisted to get up”. Incident reports for incidents occurred on 1/15/24 and 1/24/24 were submitted to the department on 2/2/24. Facility failed to follow their own protocol to call hospice services for R1 and obtain instructions of care for R1 and facility failed to report to CCLD within 7 days. (CONTINUED ON LIC 9099C) Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . Regarding allegation: Staff administered resident medications not on medication list. It is alleged facility med tech provided medication to R1 that has not been prescribed. Interviews conducted revealed 6 out of 8 residents interviewed either managed their own medication or had no issues with medication provided. 2 out of 8 residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed only Med-Techs provide medication to residents and before providing medication staff review the medication sheet and ensure they are providing the correct medication before giving it to the resident. Documents review revealed Facility’s medication administrator record for January 2024 notes R1 was provided acetaminophen 500mg, noted on a posted note dated 1/24/24 attached to medication administration record which notes “give R1 acetaminophen 500, 1 table at 10:25am” with staff initials. R1 hospice current treatment/medication/DME list does not list Tylenol 500 mg as a prescribed medication for pain between 12/13/23 – 1/26/24. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Tomoko Hino and a copy of this report, LIC 9099D, and appeal rights were provided.