complaint·January 10, 2025

Allegation: Staff did not provide safe and competent assistance with postural support of terminally ill resident. It is alleged that on June 3, 2024 at 6:09 AM Dementia resident (R1) was found laying in the hospital bed in an unusual manner. The lower part of the bed foot area was propped higher with a laundry basket. According to report night shift staff (S1) was on duty and is suspected to be the caregiver staff who placed the basket in order to prevent the hospice resident from getting up often during nighttime. According to information obtained, the incident was reported to House Manager, but no action was taken to ensure resident's safety. The resident was receiving hospice services and passed away August 11, 2024. A total of 4 staff were interviewed, of which all denied the allegation. Three (3) staff saw the 3 pictures obtained by Community Care Licensing and acknowledged staff negligence. The staff in question staff (S1) denied the allegation, and stated that a former staff (S5) was likely the caregiver that placed the laundry basket under R1's mattress. House Manager stated that former staff (S5) complained that R1's was difficult to care for and often got up at night. Manager stated that S5 said that pillows and bed rail pads were used to concave R1 in the bed in order to keep the resident in bed. House Manager stated there was disciplinary action against former staff (S5), but the caregiver refused to sign the document. There is sufficient evidence to corroborate the allegation. Based on interviews conducted, record review, and photographic evidence the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited in LIC 9099D. An exit interview was conducted and a copy of this report and appeal rights was provided to House Manager Belen Taico. Allegation: Staff are interfering with daily functions by putting residents to bed early. It is alleged that caregiver staff are putting to bed residents too early, at approximately 5:30 PM after dinner time because only one (1) caregiver staff works the night shift staff. According to information obtained, staff are doing this in order to facilitate the night shift caregiver responsibilities. Day shift begins at 7 AM and ends at 7 PM. The night shift staff work from 7 PM - 7 AM. The complaint alleges day shift staff are instructed to get the resident ready for bed after they eat dinner and before the night shift staff begins their shift. Based on interviews conducted a total of 2 caregivers work the day shift. A total of 4 staff were interviewed. One (1) out of the 4 staff stated the residents are taken to their rooms at approximately 6 PM, before the night shift staff starts their shift. Other staff stated that if the residents are placed in bed early it is out of choice. House Manager stated that former resident (R1) liked to go to bed early because they awakened early. Per Plan of Operation, residents are supposed to be prepared for bed at 8:00 PM, and residents may go to sleep at 9:00 PM, or earlier if desired. Due to Dementia diagnosis residents are cognitively impaired and were not interviewed. There is insufficient evidence to corroborate the allegation. 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 is Unsubstantiated . Exit interview conducted with House Manager Belen Taico. A copy of the report was issued.