Complaint·December 30, 2020

9099C(1).. that packages are checked when dropped off, based on prior experiences. Family members indicated they recall staff (S1) stating that S1 would take the bags to R1’s room. S1 was interviewed and stated she only checked one of the bags, which had a black computer tablet and candy. Staff interviews were conducted which provided conflicting information. Some staff indicated that staff are responsible for checking gifts or asking the contents of the package and logging packages to ensure there are no hazardous items while some staff stated that packages are only checked if they are notified by family or suspect something hazardous in the package. Administrators and staff were unable to provide a written policy . Based on medical records reviewed, On 5/10/2020, R1 was admitted to the hospital with the initial complaint of a stroke, but after further testing, resident was diagnosed with liver failure. Resident's labs were drawn on 05/11/2020 which showed resident’s Tylenol to be at 265 microgram/ milliliters. The normal range for Tylenol is 0-30 microgram/milliliters. Based on interviews conducted, if R1’s labs would had been drawn at the time of arrival, it would have been significantly higher but since Tylenol metabolizes, the level was lower at the time the blood was drawn. Interviews indicated R1 had an acute ingestion of taking over 100 pills at one time. Based on toxicologist interviewed, it was confirmed that R1 had elevated Tylenol levels and explained that there were two possible scenarios that could have occurred; either R1 ingested multiple Tylenol pills over multiple days or R1 had a "massive overdose of Tylenol more than 24 hours ago". R1’s medication log was obtained from Walnut House for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days for the month of May. It is unclear how resident obtained a large quantity and had an overdose of Tylenol. Resident’s physician report dated 2/20/2019 documents that resident is “unable to administer own prescription medications and is unable to administer own PRN medication”. Additionally, PRN Medication Statement dated 4/19/2019 indicates that resident is “unable to determine his/her own need but is able to clearly communicate his/her symptoms for a non-prescription PRN medication(s)”. Based on information obtained, the department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C(2).. 9099C(2).. Allegation: Facility staff's lack of care and supervision resulted in resident being hospitalized. On 5/10/2020, an alternative emergency ambulance medical services was dispatched to Walnut House (see 809 dated 12/30/2020 for citation issued) . It was reported that resident had an altered level of consciousness and was unable to follow basic commands. Resident appeared to have slurred speech and right facial dropping. Resident was transported to the hospital with an initial complaint of stroke. During the course of the hospitalization, resident was admitted to the intensive care unit (ICU) for acute toxic metabolic encephalopathy, decompensated liver failure secondary to Tylenol overdose, and disseminated intravascular coagulation (DIC) due to acute acetaminophen toxicity. Resident underwent multi organ failure and was placed on a mechanical ventilation. Resident’s physician’s report dated 2/20/2019 notes that the facility is responsible for managing and administering prescription medication and PRN medication. Resident’s medication log was reviewed for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days of the month of May. Based on information obtained, the department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility staff’s lack of care and supervision contributed to resident’s death. Hospital medical records document that resident passed away on 6/8/2020 at 1210 hours. The immediate cause of death is listed as Cardiorespiratory arrest. Resident had renal failure and liver failure. Hypernatremia and Dementia were listed as other significant conditions that contributed to the death but not related to the cause of death. Hospital Toxicologist stated that resident’s cause of death was multi-organ failure and stated the overdose of Tylenol was the primary reason for the multi-organ failure. Toxicologist indicated that it was clear that resident had ingested a high amount of Tylenol and explained that there were two possible scenarios of how it occurred- either resident ingested multiple Tylenol pills over multiple days or resident had a “massive overdose of Tylenol more than 24 hours ago”. Toxicologist further stated that if an individual is seen within 80 hours of ingesting cont on 9099C(3).. 9099C(3). . a high amount of Tylenol, it would be easier to determine if they could be treated. By the time resident was seen, it was over 80 hours and it was difficult to predict if resident could be treated or if they was going to recover. Additionally, facility did not communicate to the Emergency Medical Technicians (EMT’s) that resident had a history of depression and suicide attempts by overdosing on medications, which affected the approach and timing of measurements taken once resident was admitted to the emergency room. Facility told the EMT's that resident was believed to have had a stroke. Sacramento Coroner Investigator ruled resident’s death as a suicide that was caused by ingesting a lethal amount of medication. Resident’s physician’s report dated 2/20/2019 notes that the facility is responsible for managing and administering prescription medication and PRN medication. Resident’s medication log was reviewed for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days of the month of May. Based on information obtained, the department finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following three (3) citations are being issued. Failure to comply with the Plan of Corrections by the noted due date may result in a penalty(ies) being assessed. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code § 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Exit interview. Copy of report and appeal rights provided.