complaint·August 14, 2023

CONTINUED FROM FORM LIC9099 R1 was admitted to the Independent Living portion of Freedom Village on September 11, 2013. R1 was able to manage their own medications and did not require any assistance with Activities of Daily Living (ADLs). R1 was diagnosed with Myeloblastic Leukemia in 2015. R1 decided to decline further treatment and interventions such as transfusions and proceeded with hospice care. R1’s physician reported on his medical notes that by July 7, 2020, R1’s health had declined with shortness of breath and that R1 was becoming weaker due to anemia. On July 20, 2020, R1 independently contracted with Silverado Hospice for palliative care. On July 30, 2020, the hospice staff reported that R1 was alert and ambulatory. On August 1, 2020, R1 sustained an un-witnessed fall. Staff S1 arrived to check on R1 after they called for help with their alert pendant. R1 informed S1 that they fell onto a bookshelf on their right side and complained of pain. S1 evaluated R1 and assisted R1 to their recliner. After the fall, R1 complained of pain and was unable to get up and unable to perform basic tasks. S2 was notified about the fall and they notified hospice and instructed facility staff to initiate two-hour welfare checks on R1. Staff written notes documented R1 remained in bed and was experiencing extreme pain. After the resident’s fall on 08/01/20, staff provided a narrative of the incident, including a red alert report which requires a signature from resident if they refuse transport to the hospital. No signature was included on the report obtained by the Department. On August 2, 2020, staff contacted R1’s son to inform him that his mother’s health had declined. R1’s family came to visit R1 who was now bedridden with complaints of persistent pain. R1 refused to go to the hospital and her family respected her wishes. On August 3, 2020, at about 1030 hours, Hospice nurse S3 contacted the family to inform them that R1’s health had progressively declined. Family arrived at approximately 1130 hours and remained with R1 until they passed at approximately 1330 hours. Due to the rapid deterioration of R1’s health and excruciating pain they experienced, the facility failed to provide timely medical attention regardless of the resident receiving palliative care from hospice. R1 should have been treated for the injury sustained after their fall. Under Title 22, 87101 (7) "Hospice Care Plan" means the hospice agency's written plan of care for a terminally ill resident. The hospice shall retain overall responsibility for the development and maintenance of the plan and quality of hospice services delivered, R1’s fall and injury sustained was not part of R1’s hospice care plan. Under Title 22, Section 87101 regarding Falls, the facility failed to provide timely medical attention and did not report the fall to next of kin in a timely manner. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C The facility's failure to obtain required medical attention allowed R1 to experience unnecessary pain and injury following the fall sustained on August 1, 2020. Regarding the allegation: Facility failed to safeguard resident's personal item, the investigation revealed the following. Interviews were conducted with R1’s family, facility staff, and hospice care staff. S2 informed R1’s son that S2 had removed R1’s wedding ring and placed it a box for the family. R1’s son received the box but when they opened it, R1’s wedding was not present in the box and some other jewelry was present that R1’s son did not recognize. S2 provided conflicting statements and after admitted to removing R1’s wedding ring, they later recanted that statement. S2 then sent an email confirming they had in fact removed R1’s wedding ring. However, upon removing the R1’s ring, there was no documentation describing what was removed and indicating where the ring was stored for safekeeping. Based on the observations made, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Facility staff failed to seek timely medical services, Facility failed to safeguard resident's personal item, and Facility staff failed to notify resident's authorized representative after fall are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is/are being cited on the attached LIC 9099D. An Immediate Civil Penalty was additionally assessed on today September 8, 2023 for a violation of California Code of Regulations Section 87465(g) resulting in a resident's injury. An exit interview was conducted with the facility representative and a copy of this report along with the appeal rights were provided at the time of this visit.