Complaint·April 1, 2022

Allegation: Neglect of basic care: Complaint alleges there is neglect of basic care for resident (R1) including the need for frequent brief changes, repositioning, grooming, bathing, linen changes, and adequate assistance with meals. Resident moved to the facility on/around June 27, 2017 and at that time was enrolled in a health plan that offered comprehensive home and community-based healthcare services to its participants. Resident’s initial assessment completed by the facility notes that resident needs assistance with bathing/showering, dressing, personal hygiene, uses a wheelchair and is able to ambulate by themselves, and wears hearing aids. R1’s home health care plan was reviewed on 7/2/2020 as part of a scheduled semi-annual reassessment and notes that resident needs to use pressure relieving devices, including a cushion for their wheelchair, be monitored for skin breakdown and needs to change positions frequently to maintain skin integrity and be free from skin breakdown. Care plan for R1 also states that due to urinary incontinence, resident is at high risk for skin breakdown and staff at RCFE will continue routine peri-care. Resident’s care plan was updated by the facility on 9/16/2020 following R1’s return from a skilled nursing facility. R1’s updated care plan notes resident is receiving hospice services, requires assistance with a wheelchair, mainly stays in bed, is a difficult transport, and requires a two-person assist. Additionally, the care plan documents that resident needs daily hair and skin care, cleaning of their glasses, and fingernail care, as needed, and requires full assistance with dressing and bathing. The care plan also notes that R1 is scheduled to receive a bed bath on Tuesdays and Fridays during the “pm” shift, has occasional to frequent incontinence and is high risk for skin breakdown. R1’s care plan was updated by the facility on 4/1/2021 and indicates that resident is receiving hospice services, uses a wheelchair occasionally, is scheduled for a bed bath twice weekly, toileted four times in a shift, requires assistance with oral care, and needs prompts at mealtime and staff to encourage fluids. Care notes were made by multiple nurses and other medical professionals, as follows: 5/4/2021- (12:20 pm) Acute visit- (S1-, LVN) Pressure wound to sacrum/wound care performed- Bed smelled of urine - diaper "soaked with urine and copious amount of blood". No drainage/odor noted during wound care; however, picture taken of "worsening of wound.” New wound orders to be written . 5/11/2021- (11:55 am) Wound Assessment- (S2- LVN) Unspecified pressure ulcer- nurse "reinforced previous education to RCFE staff/Med-Tech about the importance of turning patient every 2 hours to avoid pressure to area and to report any worsening of condition to home health. Staff/Med-Tech verbalized understanding". 5/12/2021- (2:15 am) (S3- LVN) wound assessment/care- "found wedge in closet, turned patient to right side and placed wedge per current orders. Educated med-tech to keep wedge on patient and turn patient every two hours even if patient moves, informed that patient has saturated depends and needs changing right away. Per med-tech, patient gets assistance in feeding and only eats a very small amount maybe 25% of meals. Administrator stated to LPA Mknelly that resident disliked the wedge and that pillows were used for repositioning. 5/13/2021- (9:20 am)- Acute visit- Sacral wound assessment and care- Patient was transported by gurney via outside transport. Patient appears emaciated. Patient presents with food around mouth, large stain covering the front of dress, and food, dirt and possibly leaves or salad in blankets. Feces or dirt present under patient’s fingernails. Hearing aid in patient’s left ear appears to be caked with old food and possible spinach leaf". Report continued... Nursing notes (S4-, RN) read ” Patient reporting a "medium" amount of pain in sacrum- 8/10 on Pain Assessment in Advanced Dementia (PAINAD) scale, and states pain is constant. Patient observed to have "grimacing, moaning, striking out" during wound assessment. Nurse Practitioner performed assessment of wound –appears to have an unstageable pressure injury to left sacral region”. 5/13/2021 (1:50 pm) – Nurse (S5- RN) called Walnut House Med-Tech (S6) who could not confirm how often resident is getting changed and repositioned but stated it should be every 2 hours. RN requested S6 speak to staff that it's critically important patient is kept clean, dry and repositioned at least every 2 hours to prevent further skin breakdown. S6 indicated full understanding and she would speak to staff immediately at shift change (1430). Resident’ s pain level could not assessed but resident wanted something for pain. Patient is in diaper with strong smell of urine. Patient is very thin woman lying to her R side... unable to distinguish if wound smells foul vs smell of strong urine. 5/13/2021 (4:35 pm) -RN, S5, attempted to contact facility Med-tech for follow up question regarding how often resident is receiving PRN Norco for pain management, as patient demonstrated moderate/severe pain while under care. Nurse’s notes say "called RCFE x2 and was not able to reach any staff both times" Mon, 5/17/2021- (11:30 am) – (S7- RN) Wound Assessment and care provided- Wound measured 6 cm x 3 cm x 1 cm- “Unstageable”, pain was assessed, and PRN supply of med was checked as well as MAR. Checked incontinence brief status. Home Health nurse S5 stated in an interview on 5/20/21 that their nurse found R1 “had a foul odor " and had not been bathed for a while and the nurse demanded that facility staff give her a bath. Tues, 5/18/2021- R1was visited by Ombudsman whose notes reflect resident to be “well groomed and clean, and her clothes and bedding were also clean” although her hearing aids were not in. Resident was transferred to a skilled nursing facility by home health. Care staff S8 stated on 6/23/2021 R1 had to be changed or turned every hour or two and resident “was prone to bed sores" and R1’s nails needed to be trimmed. An individual who regularly visited R1 stated she regularly heard R1 cry out “turn me, turn me”. A family member of resident stated that resident was “ bathed every week or every other week” and did "maybe have some build up on her face". A care staff stated on 6/15/2021 “ We all noticed she did decline after she tested Covid positive- she was harder to get up- it took 2 people to transfer her from her bed to the wheelchair, adding, “she always slept in her recliner- that was her routine- since January 2020 and we would toilet her and get her dressed for bed. She then stopped sleeping in the recliner when she left with Covid positive- it took 2 people to transfer her”. A nurse with home health stated in 5/20/2021, when resident returned from the hospital to the facility after recovering from COVID, she could get in her wheelchair but then sometime after that she could not, stating she "is bedridden now". Home health notes of 4/30/21 note, "Pt. bed bound." "Continue to reposition resident every 2 hours. Resident’s care plan was updated by the facility on 9/16/2020 following resident’s return from a skilled nursing facility and notes resident is receiving hospice services, requires assistance with a wheelchair, mainly stays in bed, is a difficult transport, and requires a two-person assist. Review of the Department records shows that the facility was issued a new license on 8/6/2018 permitting 110 non-ambulatory residents, 8 of which could be receiving hospice services. LPA Mknelly confirmed with Sacramento Metro Fire that when resident's become bedridden, CCL is to be informed. Metro Fire will then assess if the room occupied meets fire regulations. Complaint alleges facility has not requested refill of PRN pain medication since 2/16/21. MAR records reviewed show that resident had a prescription for 1 tablet, Norco 10/325 mg, twice daily, as needed for pain during the day, effective 2/13/2020. Facility provided documentation, dated 2/16/2021, showing the response received to a refill request for PRN Norco- 325 mg-5 mg (1 tablet every 6 hours): “This medication has been discontinued due to treatment change”. According to MAR documentation for the period reviewed, from January 2021- May 13, 2021, there were no doses of Norco administered to resident. Home health records regularly noted between February and May 2021 that R1 was not reporting or exhibiting pain. On 4/13/21, Home Health noted “last Norco on 4/8/21”. One staff stated on 6/23/2021 that resident “never asked” for medications, but only for coffee and would say "Help" and when she would go and attend to resident, resident didn't realize she asked for help and she “wouldn't say she wanted anything”. Another staff stated on 9/10/2021, "yes, she complained about pain, but she would spit it (meds) out" and that staff did inform the doctor, by fax, and asked if they would send a nurse out to evaluate resident. A family member of resident confirmed she was NOT ordering medication refills but the home health nurse would, stating “(R1) was not able to communicate about needing pain medications" and it wasn't the facility’s fault, explaining that resident "was not asking for help" due to not being able to communicate well. Resident’s home health company nurse stated that on 5/20/2021 that resident did not receive any pain medications since 2/16/2021 when the refill ran out and resident has been in pain since then, grimacing at times; yet home health notes contradict this statement. Home health notes dated 5/13/2021 (9:20 am) document ”Patient reporting a "medium" amount of pain in sacrum- 8/10 on Pain Assessment in Advanced Dementia (PAINAD) scale, and states pain is constant. Patient observed to have "grimacing, moaning, striking out" during wound assessment. Documentation reviewed shows a new prescription was issued on 5/14/2021 for PRN Norco 325 mg-7.5 mg, 1 tablet every 6 hours, for comfort care (total 21 tablets for a 7-day supply). MAR for May 2021 shows (1) tablet of Norco 325 mg -7.5 mg was administered on 5/14/2021 as a PRN medication (time is not noted on MAR). Release of Medications dated 5/18/2021 notes that 21 tablets of Hydrocodone 325 mg- 7.5 mg were released back to R1’s responsible person (error in documentation). It is therefore unsubstantiated whether the facility failed to refill pain medications for R1. LPA did advise Administrator of the need to maintain resident records for timely review by CCL, maintaining home health records, having PRN authorization letters for residents and maintaining resident medication orders on file. Allegation: Change in condition was not noted in care plan. Resident returned to the facility from skilled nursing, on 9/11/2020, after being sent out to the hospital emergency room on 8/15/2020, and being diagnosed with Covid-19. Interviews revealed that resident was unassisted at night before contracting Covid with one staff stating, “we would toilet her and get her dressed for bed. She then stopped sleeping in the recliner when she left with Covid positive- it took 2 people to transfer her”. Interviews further revealed that resident had declined due to contracting Covid-19 and upon returning to the facility, mainly stayed in bed, was a more difficult transfer, requiring 2-persons, and needed a bed bath. Resident’s care plan was updated to reflect these changes on 9/16/2020. Resident’s care plan was updated again on 4/1/2021 based on the date and facility staff initials on the document. These updates to resident’s care were noted on the same care plan that was previously dated and initialed on 11/9/2018. It appears there were several updates made on 4/1/2021 to resident’s care plan dated 11/9/2018, including: resident now requires occasional assistance with the wheelchair, a bed bath, instead of a shower with washing assistance, toileting 4 times per shift, assistance with oral care, instead of prompts and reminders. The care plan document dated and initialed on 4/1/2021, also notes that resident is “independent” with transfers, but on hospice, which is contrary to what home health notes from May 2021 showing resident to be non-ambulatory, bedridden and receiving assistance in feeding. Based on interviews conducted and documentation reviewed, LPA has determined the allegation to be unsubstantiated. LPA advised that care plans with signatures of resident /designee participation be maintained in all resident files. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with . Copy of this report and appeal rights provided.