Complaint·February 25, 2025

observation was provided when R1 did not come out of their room for coffee or smoking. When R1 did not come to lunch, caregiver (S1) observed R1 to be using the toilet. S1 asked if R1 wanted lunch. R1 declined with head and hand gestures. R1’s family member arrived to visit R1 at approximately 2 PM. The family reported R1 was still in pajamas, blinds were closed, lights and TV were off. R1 was seated on a toilet and could not get up. Family called for assistance, 9-1-1 was called and R1 was transported to an area hospital. Medical records showed that R1 had pressure injuries to left and right buttocks as well as redness and bruising in the shape of the toilet seat. Additionally, medical records from the emergency department noted: Rhabdomyolysis, Patient confused, a&o x1. Patient has a purplish red ring around the outside of the buttocks area from being left on toilet for hours at assisted living. Also found a fluid filled blister on the R buttocks/posterior thigh. Initially, presented from assisted living facility after being found on the toilet for hours due to weakness. Mild nontraumatic and nonexertional rhabdomyolysis and AKI with CK 3469 in the absence of any trauma or exertional causes. Per collateral information obtained from (R1’s family), patient has had progressive decline in function over the last few months on top of already limited baseline mobility due to prior MCA stroke. Etiology of rhabdomyolysis is suspected due to atorvastatin medication. The Mayo clinic describes the most common signs and symptoms of rhabdomyolysis include: · Severe muscle aching throughout the entire body · Muscle weakness Report continued Complaint also alleges that Staff left a resident on a toilet for a long period of time. Based on interviews that were conducted, resident files reviewed, and medical records reviewed, the preponderance of evidence standard has been met. During a review of the Medical Records on January 22, 2025, LPA learned that the resident was on the toilet for hours. Staff records and interviews found that R1’s baseline is to have minimal verbal interaction, independently wake, dress toilet and transfer. On December 14, 2024, R1 had a change in their baseline patterns and activities. Facility staff did not recognize the change in behavior of R1 until alerted to R1’s change in condition by visiting family at 2:00 PM on December 14, 2024. No evidence was found that staff initiated increased communication efforts to determine if R1 needed assistance to get up from the toilet. R1 is known to have aphasia, English as a second language and to not readily request nor accept assistance. The caregiver assigned to R1 on December 14, 2024 has been employed for approximately 3 months. Caregiver failed to recognize R1’s change of condition. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Licensee along with Appeal Rights.