Complaint·December 1, 2023

Interview with the Executive Director (ED) indicated that the facility put in place a temporary plan of care for R1 requiring staff to conduct hourly checks due to the possibility that the call button pendants were not functioning properly in the memory care unit of the facility. Email correspondence between the ED and R1’s responsible party, dated 8/28/23, indicated that the facility will immediately begin conducting hourly checks on R1 until the facility is able to have a diagnostic check conducted on the emergency call button system. The ED indicated that a sign-in sheet was created to log the hourly checks and staff were instructed that it is necessary for them to record their hourly checks. Interviews conducted with staff (S1 & S2) indicated that care staff are to conduct hourly checks on R1 and fill out the log for the time the check was completed. Interviews also indicated that neither S1 nor S2 were aware of any care staff pre-filling the log before completing their hourly checks. Interview with S2 indicated that the hourly checks were a part of R1’s ADL/care plan until R1 moved out of the facility. According to R1’s care plan dated November 2023, R1 is to have status checks conducted 24 times per day. The facility provided the Department with the hourly check sign-in logs dated 8/28/23-9/18/23. There were several entries that were missing from the provided logs. Between 8/29/23 at 9:30pm to 8/30/23 at 2:30pm, there were no records of staff conducting hourly checks on R1. Between 9/1/23 at 5:30pm to 9/2/23 at 12:00pm, there were no records of hourly checks conducted. On 9/2/23, there were no entries between 6:12pm-10:40pm. On 9/3/23, there were no entries between 5:45am-7:05am, as well as 8:16am-10:20am. On 9/8/23, there were no entries between 12am-5am. On 9/11/23, there were no entries between 12pm-1pm. On 11/7/23, LPA conducted a visit at the care home and requested the facility provide documentation for the missing entries on the hourly check log. LPA was informed that the facility does not have any additional documentation to provide. According to the facility’s Emergency Response Systems Policies and Procedures dated October 2014, the care providers in the care home carry pagers. “When an alert is received on the pager the care provider will note if the alert is coming from one of their assigned residents and respond to the alert. If the care provider cannot promptly answer the alert because he/she is attending to another resident and cannot safely breakaway to answer the alert, the care provider will utilize their radio to request that another available care provider respond to the alert. The available care provider will acknowledge the request”. ************************************************Continued on LIC9099-C************************************************* Interview with the Vice President of Operations (VPO) indicated that there is no formal policy indicating an expected response time for staff to respond to a residents’ call button. VPO indicated that the facility’s expectation is for staff to respond immediately and that residents should not be waiting more than 15 minutes for a response from care staff. Interview with S2 indicated that staff are to respond to the call buttons right away. S2 indicated that, when care staff cannot respond to a call, they will reach out to another care staff member to respond. Interview with S1 indicated that the caregivers have pagers to inform them when a call button was pushed. Interview with R1 indicated that staff do not always come when they push their call button. R1 stated that staff have been better lately. R1 stated that maybe there are times when care staff are not available to respond to their call for assistance. According to the SMARTcare call button alert history dated between 9/13/23-9/18/23, there were 19 instances where care staff responded to residents’ calls for assistance between 26-42 minutes. There were an additional 16 instances where the alerts were never responded to. Between 9/13/23-9/18/23, there were 7 occasions that care staff responded to R1’s call button between 26 mins-35 mins and 11 occasions that the alerts were never responded to. Resident (R4) had 2 calls with a response time between 28-42 minutes and 3 alerts that were never responded to. Resident (R5) had 3 calls with a response time between 27-40 minutes. Resident (R6) had 3 calls with a response time between 34-41 minutes. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. Interview with facility maintenance staff indicated that Phillips checked the call button system on 9/13/23 to ensure it was functioning in the memory care unit. Maintenance staff indicated that the pendants were checked and were all working properly. Maintenance staff completes a check of the pendants, egress, and wander guards for the facility monthly. According to the Lifeline report provided to the facility by Phillips on 9/13/23, Phillips conducted 3 checks in both memory care and assisted living and confirmed that all pagers were receiving calls in the facility. Interview with residents (R2 & R3) indicated that their call button pendants work properly. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 conducted. A copy of this report was provided.