complaint·February 3, 2022

Allegation: "Resident fell while in care resulting in injury." Based on record review and interviews conducted the findings indicate that on 10/20/2021 resident (R1) lost it's balance and fell in the lobby by the elevator, which resulted in a brain injury [traumatic subarachnoid hemorrhage].The fall was not witnessed, but two staff responded immediately and called 911 Emergency. Video surveillance footage confirmed the resident was walking without assistance and fell backwards. LPA attempted to interview R1, but the resident was not oriented to time/place, had no recollection of a fall, nor was able to press the pendant when instructed. Resident has cognitive impairment that makes it unlikely for the resident to be able to press the emergency response pendant for assistance. Per staff interviews, R1 has a private duty attendant (caregiver) that often assists facility staff with escorting resident to meals. Per plan of operation, private caregivers are "permitted to provide services to residents in their units." All staff interviews revealed that it was an unwritten understanding that the private caregiver would escort R1 to the dining room or activities if present at the facility. However, if a resident has a private caregiver it does not relieve the facility of responsibility. Allegation: "Not enough staff to meet residents needs." Upon hospital discharge resident (R1) returned to the facility and required total care that included repositioning and feeding assistance. Facility protocol is that caregivers shall rotate/reposition resident every 2-3 hours. Per family observation the resident was not repositioned as required by physician order on multiple occasions. Facility staff was notified by R1's family that the resident's rotation/repositioning was not being performed as required. Incontinence care was not provided as needed. Staff interviews confirmed that the first 2 weeks after the resident returned to the facility rotation/repositioning assignments were missed by caregivers, and that at that time the facility was experiencing staffing shortages that contributed to missed elements of care. Executive Director stated that from October 2021- to present the facility has been short staffed 3-4 caregivers, but has been utilizing registry agency staff. All staff interviews confirmed staff shortages were the reason resident (R1's) needs were not met. During the holidays the facility had major staffing shortages. Allegation: "Resident's Care Plan not being adhered to." Based on record review and interviews conducted the finding revealed that resident (R1's) Care Plan was not followed. Resident (R1's) Care Plan requires escort assistance. Per staff interviews, the resident was on "minimal assistance", but the family was being charged for escorting assistance prior to the fall. Staff acknowledged that escorting assistance was provided, just not all the time. The Plan of Operation states: "At minimum, the staff at Pasadena Highlands will perform an annual assessment of your needs, or more frequent assessment if your condition warrants, or regulations mandate." Per R1's document review it was observed that the resident was not assessed in 2018. The Physician Reports on file were dated 8/24/2016 and 11/2/2021. Staff acknowledged that between years 2016 - 2021 there were changes in condition, but updated Physician Reports were not obtained. Allegation: "Food services are inadequate." During October 2021 - November 2021 resident (R1) was not receiving dinner meals or fed in a timely manner. It is alleged that most of the feeding issues occurred during the evening shift because R1's private caregiver is not at the facility at that time. Staff are provided mealtime feeding schedules, which include a window of feeding times. Staff interviews revealed that caregivers are to first assist with transporting residents to the dining room, and then feed residents that require assistance in their rooms. Resident (R1) did receive meals, but the meals were either received late, or staff did not feed the resident until much later. Staff acknowledged that R1 was not fed in a timely manner due to staff shortages. Staff also notified R1's family they were short staffed. Allegation: "Medications are not being administered according to physician's instructions." On January 1, 2022 the facility was short staffed, and staff (S6) informed resident (R1's) family that the evening medications had been administered. However, R1's family member was in the resident's unit all day and did not observe med-tech administer the evening medications. Staff (S6) confirmed that the medications had not been administered. Additionally, resident (R1) physician order indicated crush medications, but staff (S6) provided the resident the medication without being crushed. The med-tech also took the wrong inhaler to R1's room, but it was not administered because family member noted it was the wrong inhaler. Staff later returned with the correct inhaler medication. All staff interviews confirmed that on January 1, 2022 resident (R1's) medications were not administered according to physician order. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited according to California Code of Regulations, Title 22. Exit interview was conducted with Executive Director Brodey DeBorde. A copy of the report and appeal rights were issued.