complaint·February 28, 2025

At this facility, there are multiple buildings identified as cottages. Within R1’s cottage, there are multiple apartment-like bedrooms with their own bathroom. Each cottage also has common areas which include kitchens shared by all residents. During staff interviews, it was reported that on 04/17/2024, R1 was assisted by staff to toilet in their apartment. Staff assisting R1 left R1 on the toilet, exited R1’s apartment, and went to the cottage’s kitchen to get water for R1. It was further reported the staff told R1 to stay seated on the toilet. It was estimated the staff was gone approximately 1-2 minutes. As staff made their way back to R1’s apartment, they heard R1 yelling for help. R1 was found on the floor. Staff called for medical attention. Charting notes dated 04/17/2024 with a time entered as 8:51pm revealed the following note: R1 had unwitnessed fall in their bathroom. R1 reported they wiped themselves with no caregiver present and fell. R1 refused for 911 to be called. The Serious Incident Report (SIR) dated 04/17/2024 revealed the date of the incident was 04/17/2024 and the time of incident was 6:55pm. It reads R1 got up to wipe themselves with no caregiver present and fell. R1 had red mark on their forehead. R1 refused for 911 services to be called. In the interview with R1, R1 reported experiencing a medical event and was administered their prescribed medication (M1). Charting note dated 04/17/2024 with a time entered of 3:55pm revealed the following note: R1 experienced the medical event and was given M1. R1 reported being especially concerned about being left alone in the bathroom that day. R1 said the medication “puts me out like a light.” R1 added the sedating effects M1 can last 5-7 hours, depending on how well R1 slept the night before. Because of the sedation, R1 was unable to estimate how much time had passed between the medical event and when R1 escorted to the bathroom by staff. Once R1 was positioned on the toilet, R1 reports they told S1 to stay with them. R1 added they had to remind all caregivers about staying with R1 after M1 is provided. R1 reported staff assisting them, left the room completely and did not say anything to R1 about why staff was leaving, how long they would be gone, nor did staff ask R1 to wait on the toilet until staff returned. When staff did not return after a period of time, R1 decided to try to wipe on their own. R1 can generally wipe on their own but tends to need help from the staff to get their pants and briefs pulled up. While attempting to wipe, R1 fell forward into the shower directly in front of the toilet. R1 landed on their left arm on the slightly raised lip/edge of the shower entrance. R1 estimated they were down on the bathroom floor for about 20 minutes until a staff member came to assist. Interviews revealed R1 was complaining of pain on 04/18/2024 and R1’s POA arrived and transported R1 to the hospital. Medical records were reviewed. Discharge paperwork dated 04/18/2024, revealed an x-ray of R1’s left arm was taken on 04/18/2024. X-ray revealed a distal humerus shaft fracture. In regards to the allegation that Staff did not ensure medications were dispensed to residents as prescribed. It was alleged that a medication was discontinued without a formal physician’s order. R1 was scheduled for a biopsy on August 15, 2022. Instructions were given for R1 to terminate the medication five days prior to the surgery. During the interview with Administrator, the facility provided R1’s Medication Administration Records (MAR) for the period May-August 2022. The August MAR shows the medication Clopidogrel (Plavix) was discontinued from August 11th to August 15th, 2022. An entry states the medication was suspended due to a procedure. . Staff could not find any formal physician’s order for this discontinuation. The Administrator confirmed that such a stoppage or discontinuation of a medication should not be done without a formal order. Resident Service Director, Patricia Russell indicated that she could not find a copy of the note from the neurologist to stop the medication. Information obtained from staff members stated that a request for a stop order was never requested from the neurologist. It was revealed that the physician did not send an order to the facility because the physician was not informed to terminate the order. Facility staff made a note in R1’s chart that the medication was terminated on August 10, 2024 and was suspended until the August 15 th , 2024. Information obtained from interviews with Administrator stated that on 08/13/22, S1 gave R1 their nasal spray and it appeared to be working. She stated that family R1’s POA would visit and observed R1 resting for the first hour or so post- seizure. R1’s POA was concerned that R1 was not snapping back from the medication effects and the RP had the evening shift med tech send out R1. R1 was admitted for testing and observation. The Administrator stated that S1 did not observe any unusual behavior different from R1’s typical seizure activity, which is why she did not call 911 promptly. The previous Resident Services Director, Melissa Polendo confirmed that the RP did request permission to put up signs to educate staff about stroke signs to watch for. Polendo was not certain if staff had additional training on stroke recognition after this incident. In regards to the allegation that the Staff did not seek medical treatment for resident in care. The incident that occured on 04/17/2024. The resident was on M1 and had a history of strokes. The staff should have taken into account the R1's medical history and possibility of closed head trauma should have been the deciding factor and the facility should have taken the initiative and called 911 to have R1 sent out. It was reported that staff did not seek medical treatment for resident in care. Charting dated 8/13/22 shows R1 was seen by the med-tech after showing signs of weakness and slurring words. R1 was treated at 1443 hours for a seizure and monitored the rest of the day. R1 reported feeling better around 9 PM. R1’s POA came to the facility at 10:03 PM because the POA felt R1 did not sound good when the POA spoke to her by phone. The POA observed slurring, dizziness and poor balance, leading the POA to send R1 out by ambulance. On 8/14/22, facility records reported that tests were ongoing for a suspect stroke/TIA and a UTI. R1 was going to be transferred to an in-patient rehab facility for 1-2 weeks. Though R1 was displaying signs consistent with a stroke, staff failed to consider this possibility and did not send R1 for timely medical evaluation. R1 was eventually diagnosed with a stroke. Interview with the Administrator stated R1 was being actively monitored after the seizure. Staff indicted that they went into check on MJ every 30 minutes, even if R1 did not activate her pendant. The Administrator added that R1’s high cognitive functioning level and answering “no” to hitting R1’s head and being in pain was the deciding factor in not sending R1 out. The Administrator indicted that if the resident is competent, then the resident’s wish to go to the hospital or not go, is honored. Interviews with staff members which are corroborated by the facility’s charting dated 8/13/22 shows R1 was seen by the med-tech after showing signs of weakness and slurring words. R1 was treated at 1443 hours for a seizure and monitored the rest of the day. R1 reported feeling better around 9 PM. R1’s POA came to the facility at 10:03 PM because the POA felt R1 did not sound good when the POA spoke to R1. R1’s POA observed slurring, dizziness and poor balance, leading the POA to send R1 out by ambulance. Interview with other pertinent parties indicted that S2 correctly recognized that R1 was suffering symptoms consistent with a stroke. Staff 2 (S2) informed Staff (3). S3 then incorrectly determined R1 was suffering a seizure and treated R1 with Valium nasal spray medication. Next, S3 failed to contact the POA for five hours, even though the POA was supposed to be notified right away if there is a seizure. By the time the POA got to the facility, R1 was silently sleeping though a stroke due to the M1 that had been given inappropriately. R1’s POA immediately called 911 to get R1 to the hospital. Due to the delay by S3, it was too late for the physicians at the hospital to administer tPA, a clot-dissolving drug. R1 was ultimately diagnosed with a stroke in the same area as a previous ischemic stroke and spent about four weeks at Desert Regional’s in-house rehab center. R1’s POA said this second stroke undid all the progress R1 made recovering from R1’s first stroke. The hospital discharge paperwork dated 08/23/2022 on stated Chief Complaint: stroke, patient diagnosis: 1- Seizure, Page 17 out of 83. Page 31 of 83 stated that the patient was discharged in stable condition and to follow up with the PCP neurology and cardiology. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Based on records review and interviews, there was no information found to show that the facility made changes or attempts to change their care and supervision for the resident, based on her fall history. An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC9099D and appeal rights. In addition, an immediate civil penalty of $500 is being assessed. The LIC 421 was also reviewed, provided along with appeal rights. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.