Complaint·April 15, 2024

Per R1’s physician report dated 01/12/2023 R1 was diagnosed with Cerebral vascular accident and a secondary diagnosis of chronic kidney disease. R1 was not noted to have any mild cognitive impairment or dementia and is noted to be able to communicate needs and follow directions. It was reported on 05/08/2023 R1 was taken to the hospital due to chronic pain and returned home on 05/06/2023 with diagnosis of abnormal suputum. On 06/05/2023 it was reported on an Unusual Incident/Injury report dated 06/07/2023 that on 06/05/2023 R1’s son took them to the hospital due to complaints of R1 being lethargic and R1 was admitted to the hospital for further evaluation. Based on witness interviews R1 was diagnosed with pneumonia. It was reported by 2 witnesses that facility staff told family to not take R1 to the hospital as R1 was on hospice, R1’s family decided to take him to the hospital anyway. Based on interviews with 2 out of 2 staff indicate they did notify family that R1 was on hospice and by taking the resident to the hospital it would discontinue their hospice. Per review of hospice agreement R1 signed the documentation to enroll in Helius Hospice on 03/26/2023, based on the evaluation listed on the hospice documentation it stated that R1 had less than 6 months, which was not reflected in the physician’s report dated 01/12/2023. It was reported by witnesses that R1 was signed up for hospice by facility representative and not by the resident or resident’s responsible party. Licensee/Administrator Brevet Dao denies this allegation. Based on review of documentation from hospice Helius Hospice, LPA observed the documents to be incomplete and did not contain a plan of care. Therefore, based on the preponderance of evidence through records reviewed and observation the allegations facility tried to prevent resident from being taken to the hospital by family, facility staff decided resident should be on hospice and facility did not keep accurate resident records the allegations are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. Based on interviews with 2 out of 5 residents, they indicated R1 was moved to his wheelchair to go outside and smoke cigarettes and was moved into the living to watch TV. Per review of R1’s physician report R1 has a history of skin breakdown, but 2 out of 2 staff deny seeing pressure injuries. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations staff did not notify resident’s family of change in resident’s condition and facility staff did not prevent resident from sustaining pressure injuries are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to facility Administrator.