Complaint·April 4, 2024

This complaint investigation was referred to the California Department of Social Services Investigations Bureau (IB) and was assigned to Investigator Olivia Spindola which included a review of Cedar Sinai Medical Center (CSMC), medical records (dated 07/31/2021); interviews conducted of Staff #1, #2, #3, #4; Residents #1, #4, #5, #6; Witness #2. An interview with Witness #1 was attempted, but to no avail at the close of this investigation. The investigation revealed the following: Regarding Allegation #1 : Resident #1 was hospitalized on 07/31/21 at Cedar Sinai Medical Center (CSMC) and diagnosed with urinary retention, acute renal failure, altered consciousness, toxic metabolic encephalopathy. Resident #1 received a medical procedure on 08/05/21 at CSMC based on clinical history of diabetes militia II (DM2). Resident #1 was discharged from CSMC hospital on 08/10/21 with the diagnosis of inpatient rehab, DM2, dyslipidemia, hypertension, morbid obesity, bipolar disorder type, thrombocytopenia, and macrocytosis. Facility staff have the capability of meeting the resident’s medical needs; and Resident #1 can care for themself. A review of Resident #1’s Physician’s Report documented that the resident is ambulatory and could care for themself and does not require assistance. Interviews conducted of facility staff corroborated that although Resident #1 appears to not make the best decisions regarding their diabetic diet, facility staff ensures to monitor Resident #1’s water intake and medical care needs. Resident #1 admitted that the facility takes good care of them and is responsive to their needs. The food that is provided at the facility meets R1’s diabetic diet. Resident #1 admitted that they like to drink sodas and eat hamburgers when they are out in the community. Resident #1 stated that they get their sugar levels checked every morning and the resident can care for their own needs without assistance. Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Staff neglect resulting in resident suffering from dehydration is found to be UNSUBSTANTIATED. 03/13/24 Regarding Allegation #2 : Resident #1 has a history of recurrent falls attributed to psychosis and morbid obesity. Resident #1’s platelets were between 120,000 to 160,000 for the last six (6) months as an outpatient. Possible thrombocytopenia secondary to Depakote; hyperkalemia secondary to CKD mild; metabolic acidosis, gait disorder. Iron panel suggestive of anemia of chronic disease. Resident #1 admitted that they recall going out to the community to purchase sodas at a store when R1 tripped and fell and hit their face and was hospitalized for the fall. Resident #1 stated that the facility takes good care of them and is responsive to their needs. A review of the Incident Report (dated 8/6/2021) documented that the resident sustained a fall outside the community and was transported to Cedar Sinai Medical Center (CSMC) for observation. Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident suffered falls while in care resulting in injuries is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to Administrator (A1: Aharon Striks).