Inspector’s narrative
What the inspector wrote
Regarding the allegation that staff did not provide proper medication assistance to resident in care: it was alleged that R1 did not take their medication because staff would leave R1’s room without confirming they took the medication. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed five residents and did not obtain information corroborating that medication technicians leave residents’ rooms without confirming residents have taken their medication. However, LPA reviewed R1’s care notes which indicate on May 12, 2021, a reminder was documented for the medication technicians emphasizing the importance of staying in the room and watching R1 drink a liquid medication, advising that R1 missing doses of this medication will alter R1’s potassium levels, and advising that on May 12, 2021 R1’s family reported that R1’s dialysis nurse found R1’s potassium levels to be dangerously high. In addition, LPA reviewed R1’s MAR which indicates R1’s Sevelamer Carbonate 800MG was not documented as being given for the noon dose on January 24, 2022.
Regarding the allegation that a resident's call button was in disrepair: it was alleged that R1’s call button was not functioning for three weeks in January 2022. LPA reviewed the facility’s internal communications which document that the entire call system stopped functioning on February 16, 2022, and checks were conducted on all residents in lieu of the call system. However, per the facility’s’ internal communications, on February 17, 2022, a caregiver checked on R1, R1 complained that they had been calling for assistance, but the caregiver documented that the call light system was still not working and they had only checked on R1 because of their rounding. R1’s care notes and the facility’s internal communications do not document any issues with the call button system after February 17, 2022. Facility staff were supposed to conduct regular checks on residents while the call system was not working, but the information obtained shows that R1 was calling for assistance for an unknown length of time, the caregiver did not receive the signal or respond timely, and the caregiver only checked on R1 as part of their last check without realizing R1 had been calling for assistance.
Regarding the allegation that facility did not maintain grab bars for each resident toilet: it was alleged that R1’s room did not have grab bars for the toilet and staff did not correct the issue. Per the facility’s resident roster and R1’s MAR, R1 resided in Room 165. LPA interviewed the facility’s maintenance director who stated there are two styles of bathrooms, where the old style has a sink that goes up to the toilet and the sink can be used as a grab bar, and the new style where the sink is far from the toilet and cannot be used as a grab bar. Per the facility’s maintenance director, grab bars are installed when requested by residents’ families.
LPA inspected the facility and confirmed that the old style has a sink that goes up to the toilet and could possibly be used as a grab bar, but Room 165 does not have separate grab bar installed on the sink and the edge of the sink does not provide the same gripping surface as a true grab bar, meaning it does not meet the requirement that every toilet have a grab bar. In addition, LPA noted room 206 has the new style where the sink does not reach the toilet and there is no grab bar installed on the toilet.
Regarding the allegation that staff did not complete a reappraisal on resident in care: it was alleged that in January 2022, R1 had a fall resulting in decreased arm mobility and the facility did not conduct a reappraisal or update R1’s care plan prior to R1 leaving the facility in February 2022. LPA reviewed R1’s care notes which document that on December 15, 2021, R1 had a fall, went to the hospital, and was picked up by their family to stay with their family. Per R1’s MAR, R1 returned to the facility on January 6, 2022. LPA reviewed R1’s care notes which document that on December 22, 2021, facility staff communicated with R1’s family regarding R1’s change of condition after their fall and documented R1’s new care needs and how they would be met. LPA reviewed a copy of R1’s service plan marked up on January 6, 2022 by the facility’s wellness director at the time that documents R1’s new care needs and documents that the facility would use a wheelchair for R1, but this document was never finalized. Per R1’s care notes, when R1 returned to the facility on January 6, 2022, facility staff requested an updated physician’s report from R1’ doctor and planned to update R1’s service plan. R1’s care notes document that on February 18, 2022, a care plan meeting was held with R1’s family, it was explained to R1’s family that R1’s service plan had not yet been updated because the facility was still waiting on an updated physician’s report from R1’s doctor, R1’s family was advised that staff are all aware of R1’s new care needs and the required care was being provided, and R1’s family advised the facility that R1 would be moving out. While the facility noted R1’s new care level and claimed to provide the newly required services, the facility did not need to wait for the new physician’s report in order to finalize the changes already discussed with R1’s family. In this case, R1 returned to the facility on January 6, 2022 and did not have a finalized updated service plan by the time they moved out on February 19, 2022.
During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.
Civil penalties for repeat violations are being assessed. See LIC421FC.
An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
It was alleged that when R1’s call button did function, R1 had to wait 30 minutes or longer for assistance from staff. LPA interviewed the administrator at the time who stated the average wait time is five to 10 minutes, with the old call button system wait times could not be tracked, but with the pendant system installed on March 1, 2022, they can now track wait times. LPA interviewed five residents and did not obtain information corroborating long wait times. LPA reviewed the facility’s internal communications which document that on February 9, 2022, R1 called for assistance at 5:08AM, requested a medication from the caregiver, and the medication was provided to R1 by the medication technician at 5:20AM. The facility’s internal communications also document that on January 21, 2022, at 5:40AM, R1 requested assistance, assistance was provided by a caregiver, and the encounter was completed and documented by the medication technician minutes later at 5:53AM. These incidents demonstrate rapid response times by staff. Per the facility’s internal communications, on February 11, 2022, R1 requested assistance at 3:08AM, stated they were hungry and wanted the medication technician to warm up the soup in their fridge and feed them, the medication technician advised R1 that they could not because they had to attend to other residents, and the medication technician went back and confirmed R1 was fine prior to 5:36AM when the encounter was documented. This incident demonstrates that R1’s call was answered, R1’s request could not be immediately fulfilled, and the staff checked back later to ensure R1 was doing well, although additional details, including whether R1 withdrew their request to eat so early in the morning or when the staff made their second check, were not documented and the staff no longer works at the facility. The information obtained is conflicting.
Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
