complaint·March 10, 2023

The investigation revealed the following: Regarding allegation: "Staff not assisting resident with ADLs. " It is alleged that R1 was weak and in severe discomfort, has been in pain for 8 days and constipated for 3 days with a pain level of 10 out of 10 and nausea level 8 out of 10. Based on documents reviewed, on 9/23/2020 R1 was admitted at Huntington Hospital and assessed by EMS. EMS observed R1’s “urine in the Foley to be dark in color and cloudy”. LPA reviewed R1’s Medication Administration Record (MAR) for Sep 2020 and it revealed that R1’s medication Zofran was not administered, and pain medication Morphine was last given on 9/20/2020 & 9/21/2020, two (2) days prior to R1’s hospitalization. Hospice communication log revealed that on 9/21/2020, Hospice RN reported the following: R1’s Foley catheter was not changed the night before, Foley was leaking around and Foley drainage slightly cloudy. (5) out of (6) residents interviewed indicated that they are independent in many ways, and they only need assistance with medication. Interviews conducted with staff members indicated that the Med-Tech and Caregivers were trained to clean and drain the Foley catheter bag. Staff also revealed that the facility’s daily notes and log were communicated verbally. Regarding allegation: “Staff did not observe changes in resident's health.” It is alleged that R1 started experiencing pain two (2) days after a Foley catheter was placed. But facility staff do not check on R1 enough and that he has been in pain for 8 days and constipated for 3 days with a pain level of 10 out of 10 and nausea level 8 out of 10. Based on documents reviewed, on 8/11/2020, R1 was admitted for care at the facility per admission agreement. Then R1 was admitted on 9/23/2020 at Huntington Hospital and assessed in by EMS, “urine in the Foley to be dark in color and cloudy”, “weak and in severe discomfort, with a pain level of 10 out of 10 and nausea level 8 out of 10.” EMS observed “rigidity, pain, distension, and tenderness in all four quadrants” of R1. (5) out of (6) residents interviewed indicated that they are able to do daily living activities on their own and they only need assistance with medication. Interviews with the staff revealed that there were enough staff per shift to check on residents and the facility’s daily notes and log were only communicated verbally. Based on LPA’s interviews, and review of documentation regarding R1, 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, due to the facility failed to observe changes in resident’s health which resulted in resident experiencing severe pain and discomfort while in care. Refer to LIC 421IM*** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.