complaint·December 30, 2022

On 9/30/21, LPA Chan conducted an on-site visit to interview 4 Staff and 10 Residents. LPA requested for the staff roster, resident roster, and facility notes pertaining to Resident #1. The allegation – Resident is not being rotated resulting in pressure injuries was investigated by an Investigation Branch personnel. The Investigation revealed the following: Regarding allegation - Resident is not being rotated resulting in pressure injuries. The Department of Social Services Investigation Branch (IB) Investigator, Peter Zertuche, conducted interviews and obtained medical (Hospice) records for Resident #1 to determine the findings of this allegation. The information obtained from the interviews revealed that Resident #1 was not being rotated resulting in pressure injuries. Per the Mt. Olive’s Hospice agency care plan, Resident #1 was admitted to this hospice agency with a stage 2 wound in the coccyx area on 12/21/2020. The notes stated to rotate every 2 hours and to change diapers often to ensure the coccyx area is dry at all times. The interviews revealed that caregivers did not change the diaper nor reposition regularly during some shifts. Per interview with Resident #1’s family member, the individual stated no staff came in to check on resident while visiting for 4 hours on one of the visits. Although Staff interviewed denied not rotating resident every 2 hours, the resident’s wound eventually worsened to a stage 3 by 2/1/21. There was no updated care plan nor contact made with the doctor once the wound worsened. Based on interviews and record review, there are supporting evidence to substantiate this allegation. For allegation – Resident’s medication is not being administered. It was alleged that Resident #1 (R-1) did not receive insulin on a daily basis. According to interviews conducted by LPA Chan, R-1 was able to self-administer the insulin until R-1’s health condition worsened and could no longer administer consistently. A Med Tech confirmed that due to the facility staff not being skilled professionals to inject the insulin on the resident, the hospice nurse came to administer the injection when they were called. Based on facility’s medication record and hospice notes, the medication that requires injection, Insulin Lispro 100/ML 5X3 ML was not consistently taken in December 2020 to January 2021. The notes on the MAR logs indicated the medication was either withheld due to the blood sugar level, R-1 refused, or that R-1 was physically unable to take. Based on the information gathered, R-1 did not take the injection daily as ordered by the physician and the hospice care plan did not state the hospice nurse was responsible for providing the injection on a daily basis. There is sufficient evidence to substantiate this allegation. (Continue on LIC9099C) Regarding allegation - Resident’s diapering needs are not being met. LPA reviewed Resident #1 facility’s Service Plan and hospice visit notes which indicated that Resident #1’s diaper needs to be changed often to keep buttock area dry, preventing the open wound to occur or get worse. LPA Chan interviewed 3 care staff who stated they changed Resident #1 every 2 hours. Interviews conducted by Investigation Branch (IB) Zertuche also revealed that Resident #1 was found with soiled diapers during some visits by the hospice nurse and/or shift change of staff. According to the Mt. Olive’s Hospice Agency notes, the hospice nurses documented Resident #1’s diaper being soiled for at least 5 of their visits. It was also noted that Resident’s dressing in the buttock area was soiled with urine and/or feces while being changed by the hospice nurse. Based on documents and interviews gathered, there is sufficient evidence to show that the resident’s diapering needs were not met. R egarding allegation – Facility staff are not following resident’s dietary needs . It was alleged that Resident #1 was given orange juice when not supposed to and was also given ice cream and milk. According to the Mt. Olive Hospice Visit Notes, it is specified to avoid giving Resident #1 orange juice which could cause the blood sugar level to increase. Staff were instructed to give Glucerna (food supplement) if resident refuses to eat and was indicated on the hospice care plan. LPA Chan interviewed 2 Staff who provided care to Resident #1. One staff stated that Resident #1 was near the end of life, therefore, felt it was okay to give a little bit of orange juice, while the other did not know if the doctor instructed not to give orange juice. It was also noted on some of the hospice nurse visits, the caregivers were reminded not to give orange juice to the resident which caregivers verbalized understanding. However, orange juice was observed by resident’s bedside during some of the hospice visits. As for dairy products, staff knew Resident #1 was allergic to dairy and did not provide any of it. Based on interviews and documentation, the facility staff did not follow the dietary plan and gave Resident #1 orange juice. There is sufficient evidence to support this allegation. Based on interviews and documents, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** The issuance of an additional Civil Penalty is being considered based on health & Safety Code 1569.49(f); If the Department determines serious bodily injury occurred. An exit interview was conducted. The Plan of Corrections were reviewed and developed with staff. A copy of this report and appeal rights were provided.