complaint·June 12, 2023

(CONTINUED FROM LIC9099) eleven (11) facility staff and hospice staff. Three (3) of eleven interviews revealed, either the staff did not work at the facility during R1's residency or did not remember R1. Seven (7) of eleven (11) interviews revealed R1 was able to eat and drink without assistance and was awakened, if asleep, when their meal/fluids were delivered. R1 was unable to be interviewed. Regarding the allegation "Resident was deprived of oxygen", it was alleged that on 04/28/2021 R1 was found unconscious, without their oxygen, having trouble breathing, and that R1's oxygen machine was found to be turned off and out of reach. It was further alleged that R1 was to be on oxygen 24/7 as ordered by their physician yet R1 had been found sitting at their table without oxygen on multiple occasions. Several records pertaining to R1 were reviewed. Review of R1's Physician's Report dated 01/27/2021 indicated R1 was not able to administer their own oxygen. A review of R1’s Personal Service Assessment dated 03/12/2021, indicated R1 required the use of oxygen or respiratory equipment and either R1 or their physician believed R1 needed help such as staff attention or physical assistance with the use of oxygen or respiratory equipment. Alternatively, review of R1's Personal Service Plan dated 04/14/2021 revealed R1 was independent with using oxygen or respiratory equipment. The Personal Service Plan was signed by R1's responsible party on this same date. Interviews were conducted with twelve (12) facility staff and hospice staff regarding R1's oxygen use. Four (4) staff/witnesses interviewed reported R1 was known to remove the oxygen. One (1) staff interviewed reported they could not recall any issues or concerns regarding R1's oxygen use. No interviews corroborate that R1 was found unconscious at any time. Investigation did not find that R1 required medical attention on or around 04/28/2021. R1 was unable to be interviewed. Regarding the allegation "Facility failed to provide sanitary conditions in residents bedroom", it was alleged that the carpet around R1's bedside commode had urine on it and staff failed to clean it timely. A witness interview claims it took two weeks for the facility to clean the carpet. Facility staff report the carpet was cleaned the same day. R1 was unable to be interviewed. The investigation did not find any documents to corroborate or refute the allegation. Regarding the allegation "Facility does not have enough staff to meet resident’s needs", it was alleged that R1 required assistance in using the bathroom and on more than one occasion staff would respond 30 minutes after R1 had activated their call button or staff would not respond at all. Interviews were conducted with ten (10) residents and one (1) witness. Two (2) residents were unreliable historians and one (1) resident reported they had never utilized their call button. Six (6) residents interviewed reported they found staff response times to call buttons to be "not very long", "come pretty quickly", "usually quickly", "not very long", "3 to 5 minutes", and "5 minutes, something reasonable". (CONTINUED ON LIC812-C) (CONTINUED FROM LIC9099-C) One (1) resident reported they found staff response times to call buttons to be "sometimes a long time and some caregivers are great!". One (1) witness interviewed reported they had observed staff response times to call buttons to be "mostly quickly". R1 could not be interviewed. Investigation did not reveal documents to corroborate nor refute call times. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided along with LIC811- Confidential Names list. (CONTINUED FROM LIC9099-A) revealed they had visited R1 at the new facility "within a day or two of being placed". The RN reported that when R1 came into placement to the new facility, R1 had a "reddened area" on their coccyx. R1 was examined by R1's responsible party's personal doctor on 05/06/2021 at the new facility. Notes documented for that visit revealed R1 was observed to have "erythema without skin breakdown at top nadal cleft" and "grade 1 decub ulcer natal cleft". The doctor's notes do not indicate an order for treatment for it. On 05/13/2021, the doctor visited R1 once again at the new facility and notes reviewed for that visit revealed the grade 1 decub ulcer to R1's natal cleft had progressed to a grade 2. Review of progress notes for R1 at the new facility revealed no mention of a redness to R1’s coccyx upon admission. Progress notes for the overnight shift of 05/04/2021 to 05/05/2021, three days after R1’s admission to the new facility, revealed R1 was rotated every two hours because of skin breakdown. There is no mention of where the skin breakdown was located. Regarding the allegation "Unqualified staff caring for resident", it was alleged that on one occasion the facility bus driver was assisting R1 due to staffing being short that day. Interview was conducted with Staff #1 (S1) who was identified as the bus driver observed providing care for R1 that day. S1 reported they remembered the day they assisted R1 in 2021. S1 reported staffing was difficult that day due to absences related to COVID-19 and they were asked to assist residents as needed. S1 reported they assisted residents including R1 with toileting or showering. S1 reported they had been a caregiver at another facility prior to their employment at Brookdale Murrieta and were familiar with the required duties. Additionally, S1 reported they had received extra training in the form of shadowing the caregivers upon being hired at Brookdale Murrieta. A review of S1’s staff record revealed proof of required training. This agency has investigated the complaint alleging "Staff neglect resulted in resident sustaining a pressure injury" and "Unqualified staff caring for resident". We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.