complaint·February 18, 2025

Staff did not properly transfer a resident resulting in an injury. It is alleged that on July 31, 2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. According to information obtained, when the wet resident was being transferred out of the bath chair to the toilet, the resident was only assisted by one (1) staff (S1) instead of two staff, and staff (S1) gripped R1's hand in order to prevent the resident from falling. According to information obtained, R1 was assessed as a 2-person assist after a previous incident in March 2024 determined the resident was in need of two staff assistance during bathing and transfers. A total of seven (7) staff were interviewed. Staff (S1) stated that on 7/31/24 at approximately 7 AM, R1 was assisted into the bath by two staff, S1 & S2, but left the room to check on the resident next door, and was not present for assistance out of the bath chair. Staff (S2) stated that S1 screamed for S2's help. R1 had a hand a long and thin skin tear on the right hand. Staff (S1) said that R1's son had instructed staff to transfer the resident out of the bath by holding their hands. Both staff stated they immediately notified former med-tech staff (S8) of the incident and 1st Aid care was provided to the resident. Staff (S1) stated a skin integrity assessment form was completed, it was documented on the end of shift book and shower chart located in R1's room. Wellness Director and Administrator confirmed that former med-tech (S8) did not notify Administrator or Wellness Director, write any chart notes, notify R1's Physician or family, nor mentioned the injury at change of shift. Administrator stated that S8 communicated with PM med-tech former staff (S9) to monitor and change the bandage, but said the tear was minor and 1 cm in length. Staff (S)9 did not check the wound until late at night and discovered the wound needed medical attention. At approximately 10:30 PM, R1 was sent out to the hospital as non-emergency. Based on the picture of the injury, staff agreed the hand injury required a medical assessment by a physician after AM med-tech (S8) assessed the hand injury during the 1st Aid assessment. Therefore, there is sufficient evidence to corroborate the allegation. (2 of 7) Allegation: Staff did not seek timely medical attention for a resident. It is alleged that on 7/31/2024, resident (R1) sustained a hand injury at approximately 7 AM that required medical attention because the skin tear was approximately four inches with exposed flesh. According to information obtained, PM caregiver staff (S9) called Kaiser Permanente Hospital for an ambulance until approximately 10 PM. The hospital doctor applied glue and wrapped the wound with gauze. The resident returned to the facility at approximately 4 AM. Based on seven (7) staff interviews the findings revealed that former AM med-tech staff (S8) failed to call R1's physician for directions regarding the skin tear, and did not seek timely medical attention for the hand wound tear that required medical attention. Caregiver staff interviewed stated they followed protocol by immediately reporting the incident to the AM med-tech staff, whom after the initial injury assessment should have seek out medical advice and/or medical attention. All staff acknowledged R1's physician should have been contacted immediately after the injury. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not ensure that resident's toileting needs were met. The complaint alleges that resident (R1) requires full assistance with incontinence care and is supposed to be changed at least every 2 hours. It was reported that the incontinence logs in the resident’s room had 6-hour gaps of missing staff documentation indicating incontinence care was performed. The resident’s responsible party and/or other family members arrive at the facility daily at 9 AM and stay until approximately 9:30 PM. According to the report, family have observed the resident soiled primarily during early morning hours. On Saturday August 10, 2024, the responsible party arrived at approximately 9 AM, it was observed that the bed sheets were soiled with urine. Six (6) out of 7 staff denied the allegation and stated resident (R1) is being checked every 2 hours and changed, but that sometimes staff forget to document the completed task. Two (2) staff stated that during Summer 2024 there were reports that night shift caregivers were not completing incontinence care as required. LPA reviewed and gathered pertinent documentation that revealed that facility caregivers did not perform 2 hour checks on the resident on numerous occasions in the month of July 2024.Therefore, the allegation is deemed substantiated. (3 of 7) Allegation: Staff mismanaged resident's medication . It was reported that on July 6, 2024, AM med-tech staff left R1’s responsible party a note asking them to contact Kaiser requesting a refill for eye drop medication “Latanoprost 0.005 %” because the medication ran out. The medication was picked up by family until July 9, 2024, because staff informed family staff were not able to pick up the medication. According to the report, the facility has authorization to request refills from Kaiser and Yorba Linda pharmacy. Moreover, it is also alleged that on August 8, 2024, at 6 PM, R1 was administered bedtime medication Donepezil HCL 5mg, which is supposed to be administered between 8 PM – 9PM. Family was in the room when Wellness Director went into R1’s room at 9 PM to administer the bedtime medication that had already been administered by the med-tech at 6 PM. A total of seven (7) staff were interviewed . It was acknowledged that some of R1’s medications were not administered on August 8, 2024, and that med-tech administered a bedtime medication at 6PM but failed to document on the Medication Administration Report (MAR). Wellness Director confirmed that on August 8, 2024, R1’s family stated the medication had already been administered at 6 PM. Therefore, Donepezil was not administered. According to staff interviews, bedtime medications are typically dispensed at 7:30 PM. MAR records indicate eye drops Latanoprost 0.005% appear to have not been given consistently. Staff acknowledged that med-techs should have requested the eye drop refill in a timely manner. Records indicate there is sufficient evidence to corroborate the allegation. Allegation: Staff do not ensure a safe environment is provided for residents. It is alleged that In July 2024 the front doors of the facility were being left unlocked 24 hours a day even though the front door entrance is supposed to be locked at 7 PM, and young male (18-22) outsiders have been observed entering the facility after 8PM to use the 1 st floor public restroom. On August 1, 2024, resident (R1’s) responsible party emailed Administrator notifying her of the safety concerns regarding the unlocked doors, and she immediately addressed the issue with PM staff. However, on August 3, 2024, R1’s responsible party went to the facility at midnight to check if the front door was locked. It was found to be unlocked and accessible to outsiders. All seven (7) staff confirmed that the front doors were being left unlocked by PM staff. According to staff interviews, PM med-techs are responsible for locking the doors at 7PM but have been known to leave the doors unlocked when they exit the facility for breaks. Staff reported that on several occasions homeless in the area have tried entering the building, and after 6 PM there is no receptionist on duty. Therefore, the allegation is substantiated. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Pursuant to Title 22 California Code of Regulations, the following deficiencies were cited (refer to LIC 9099D). Exit Interview was conducted, citations issued, appeal rights discussed, and a copy of the report was issued to Administrative Assistant Katie Manriquez. Allegation: Staff did not report incident involving resident as required. It was reported that resident (R1’s) responsible parties were not immediately notified of the hand tear injury sustained at approximately 7 AM on July 31, 2024. The complaint alleges that R1’s son/responsible party arrived at the facility at approximately 9 AM and that is when staff informed the responsible party of the injury. A total of seven (7) staff interviews were conducted. The findings reveal that when a resident sustains a serious injury the residents’ responsible party is immediately notified if the resident is being transported by emergency services. However, if the resident’s injury is not deemed serious then, then med-techs may notify the responsible party a little later. In this case, former med-tech (S8) did not categorize the injury as serious, and since R1’s family members and responsible party visited the resident at approximately 9 AM daily, staff waited to communicate to the responsible party upon arrival to the facility. Based on information gathered there is insufficient evidence to prove the allegation, because the resident’s responsible party was notified within a reasonable time according to records reviewed. Allegation: Staff failed to provide adequate food service. It is alleged that on Saturday, August 10, 2024, resident (R1) informed their responsible party that they had not eaten breakfast because staff dropped the cereal on the floor, picked it up, and attempted to feed the cereal to the resident, but the resident refused. Based on staff interviews, R1’s responsible party notified staff that there were Cheerios on the floor and when a staff person went into the room Cheerios were observed on the floor. However, it is unknown if only a few Cheerios fell on the floor or the whole bowl fell. Since there were no witnesses and resident (R1) has cognitive impairment there is insufficient evidence to prove that service procedures were not followed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to Administrative Assistant Katie Manriquez.