complaint·March 20, 2022

Home Health Registered Nurse (RN) notated on 5/27/2021, RN instructed patient (Resident/R1) and caregiver on use of assistive devices to ensure R1 is safe, R1 is always to use assistive device when up, R1 needs stand-by assistance to ambulate at all times. Home health instructed on environmental safety issues to resolve immediate hazards, keep clear pathways, eliminate clutter, keep telephone close, remove throw rugs. Records noted R1 has a diagnosis of dementia. Home Health records notated by RN dated 6/4/2021: R1 said R1 feels as if R1 is burden to staff as R1 needs assistance to ambulate or use restroom. Per R1, R1 is told rude comments by staff and make R1 feel very uncomfortable belittled. Nurse noted there is a camera in the room to monitor R1 if abuse is happening per POA (Power of attorney). In addition to R1 revealing to home health that staff made rude comments and belittled R1, R1 made similar statements and provided examples to others. This department learned through interview and review of text exchanges scribed by Licensee Lita, on 6/8/2021, R1 landed on R1’s “tush.” Staff heard the bell and headed to R1’s room. Lita writes that when R1 doesn’t have tremors, R1 is able to get up and walk on R1’s own to the kitchen area. Lita goes on to state that, “There are times when R1 just want to be catered to and would insist that R1 would rather ride on R1’s walker.” On 6/11/21, Lita communicated that the night prior at 9PM, R1 was found on the floor and took another fall during the night. Lita communicated that night shift always puts on the monitor and was seen by staff walking. Home Health records dated 6/21/21, notated by home health occupational therapist (OT), OT conducted a Fall risk assessment which revealed R1 is at risk for falling, depends entirely upon another person to dress and bathe. R1 needs assistance to toilet and transfer. R1 is able to walk only with supervision or assistance from another person at all times. R1 is a max assist with 24-hour care/supervision. Caregivers tell R1 to wait to use the bathroom so they can assist but due to resident frequently forgetting and attempts to ambulate on R1’s own. OT noted on 7/13/21, R1 and caregiver reported a fall occurred over the weekend. R1 requires max verbal cues and tactile cues to complete task. R1 Requires caregiver assist for balance and frequent rest breaks. Caregiver educated regarding risks of decreased activity including increased falls. Cont'd 9099-C In a text dated 8/11/21, Lita states, “R1 been acting/feeling out of sorts last couple of days. I think it’s the Parkinson that’s making R1 act this way. R1 did end up being down on the floor once yesterday and again this evening. R1 gets out of bed forgetting to ring R1's bell and starts walking. on R1’s “falls" we don’t know how it happens. Yesterday we hear the noise and found R1 by the bed facing the lamp table. Tonight, R1 is in bed shortly after dinner, then, I was in the dining room doing medications for tomorrow…I heard a noise, run to R1’s room and R1 is on the floor in a sitting position leaning against the wall between the door and the cabinets where R1’s Christmas lights is the wheel chair is by R1’s feet.” In the text Lita states, R1 was not distressed and placed back in bed. Lita acknowledges R1 was not being supervised at time of fall. Licensee/administrator did not seek immediate medical attention for this fall nor was the doctor or CCL notified by Lita although she reports R1 is “acting/feeling out of sorts.” This department reviewed a picture of the area described by the licensee. The picture is of a hole in the wall where the fall is described to be. This department reviewed video of the room prior to the fall which did not reveal a hole in the wall. Lita acknowledges there was a “dent” in the wall that she had not noticed prior to the fall but does not know if that’s what caused it. R1 was diagnosed with a urinary tract infection August 16 th , 2021 An incident report submitted by Lita to CCL, notates that on 8/26/21, R1 suffered a medical emergency at which time 911 was called and R1 was hospitalized. On 8/30/21 per Lita, family would like R1 to return on hospice. Lita requested and was granted an increase from 2-3 residents on hospice with CCL provided she ensured substantial compliance. R1 returned to the facility on 8/31/21 on hospice. Lita said she did not have a conversation with hospice as to the plan of care due to the short time frame. Lita did not obtain the Hospice care plan. Cont'd 9099C This department was provided with a picture of a urine saturated diaper that was taken at 12:30 AM on 9/3/21, with a message that R1 had not been changed since before 3 the day prior. This department obtained witness statements that when Lita was confronted about the lack of care, Lita admitted to being understaffed. The department learned that on 9/3/21, an additional family moved their loved one (R2) out of the facility who was also on hospice. On 9/3/21, two of the three residents on hospice were moved out of the facility by their responsible party due to lack of care and were told by Lita that she didn’t have the staffing and couldn’t find anyone to hire. On 9/17/21, Lita provided the department with staff schedules for August and September of 2021. A review of the schedules provided revealed that there was not staffing scheduled between 6pm and 11PM during the time R1 had returned from hospice. Lita stated she lives at the facility and covers during this time. Lita stated her sister Becky who is also staff lives at the facility and will respond if needed. Substantiated : Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.