complaint·October 27, 2023

On May 24, 2020 R1 was transported back to Huntington Terrace from Anaheim Global. Upon arrival, R1 was noted to be lethargic and weak which was consistent with progress report updates received in the days prior. The staff and R1’s responsible party believed at the time R1 to be over medicated. Huntington Terrace staff reported R1’s condition to an approved Doctor and on May 25, 2020 received orders to cut R1’s medication dose in half. On May 26, 2020 staff noticed a change in R1’s condition and informed R1’s responsible party and approved Doctor. R1’s approved Doctor recommended R1 be sent out to the hospital. Staff reported they offered to call 9-1-1 but R1’s responsible party declined, instead stating they would take R1 to the hospital. Interviews conducted with R1’s responsible party disputed staff’s reports, stating that facility staff offered to have R1 assessed by the facility doctor a few days later on May 28, 2020 instead of taking R1 to the hospital. R1’s responsible party declined and took R1 to the hospital after consulting with a family member in the medical field. R1’s preplacement appraisal completed on May 24, 2020 notes R1 was able to bear weight using a front wheel walker with assistance. R1 was admitted to the hospital on May 26, 23 at 5:13PM and was diagnosed with dysphagia, Lacunar Stroke and Right Hemiparesis. The medical records reviewed notes that R1’s responsible party told hospital staff R1 was lethargic and weak upon being picked up from Geriatric Psych. Hospital records reviewed further notes that R1’s responsible party informed hospital staff R1 called them on May 23, 2020 and reported having right sided weakness, a day prior to R1 being transported back to Huntington Terrace. R1 was further diagnosed with an Acute kidney injury due to dehydration which was noted to be resolved as of May 28, 2020 with IV hydration. Due to the dysphagia R1 was ordered to have a feeding tube and required pureed diet and thickened liquids. Findings from R1’s chest X-Ray notes chronic lung changes compatible with previous granulomatous. Per facility records, R1 was listed as participating in the facility’s meal club due to requiring assistance with feeding and having a special diet upon return on May 24, 2020. Facility meal attendance tracking records note that R1 refused to eat dinner the night of May 24, 2020. The following day R1 was noted to eat Lunch but did not eat dinner. A day later, records show R1 ate all three meals in their room. Although facility staff did not immediately call 9-1-1, interviews and records obtained confirmed staff were communicating with R1’s approved Doctor regarding R1’s condition and were following physician orders. It remains unclear at this time if the actions taken by the facility were sufficient to determine if timely services were sought. CONTINUED ON 9099C Furthermore, although R1 was refusing meals, documentation observed and interviews conducted could not corroborate if R1’s dietary needs were not being met due to R1’s choice to refuse services or facility staff neglect. Therefore, based on a records reviewed and interviews conducted, the allegations that Staff did not seek medical attention for resident in a timely manner and Staff did not ensure that resident's dietary needs were met was determined to be Unsubstantiated. Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit.