Complaint·February 11, 2025

LPA Moleski reviewed a note from visiting hospice staff on 10/26/24 which indicated that there was no discoloration or bruising on R1 at that time. LPA Moleski reviewed daily progress notes for R1, which were recorded by facility staff. A note on 10/25/24, R1’s date of admission, indicated that R1 was "in pain very often and medicated as needed." A note on 10/27 indicated R1 didn't sleep well until 3:30 a.m., and R1 continued to ask for pain medication. A note on 10/28 indicated R1 slept in short intervals and "keeps moving." A note on 10/29 indicated R1 was "very restless" overnight and didn't go to sleep. R1 was found on the floor around 4:30 a.m., although R1’s bed was set "all the way low." A note on 10/30 indicated the R1 was "very restless," and "went on floor." Staff put R1 back to bed, but "[R1] goes on floor again." A note on 10/31 indicated that R1 "was on floor around 10:30 p.m." R1 was put back to bed with a Hoyer lift. A note on 11/2 indicated R1 was "restless always." A second note on this same date indicated that R1 was "restless," but went to sleep later. A note on 11/3 indicated that R1 was "very restless." The author of the note wrote that staff put pillows by the side rails of the bed, but R1 threw them on the floor. R1 was "hitting [R1's] head on rails" and hitting their feet on the walls. A skin tear was noted on R1's feet and arms. A note on 11/4 indicated that R1 slept for a while, but then was very restless. The author said they were "watching [R1] alway" [sic] and "holding [R1's] hands." A second note on the same date indicated that R1 was restless for a short time, but after taking their medication, R1 went to sleep. The Community Care Licensing Division (CCLD) did not receive any incident reports regarding the falls as described above, or regarding the injuries suffered by R1. In an interview, R1’s RP said they were not notified of the injuries, and discovered them when visiting R1. In an interview, Barias said that R1’s RP was not notified of the injuries, and that she herself was not notified by her staff of the injuries. R1’s hospice nurse said the hospice agency was not notified of the injuries, and they discovered the injuries when visiting R1. LPA Moleski reviewed R1’s hospice care plan, dated 10/21/24. Admission instructions indicate that both R1 and caregivers were provided 24-hour contact phone numbers for the agency. A note in the care plan indicates that both the patient and caregivers were instructed on how and when to call hospice, and to do so on an as needed basis. The care plan identified R1 as a fall risk, and instructed staff to conduct a fall risk assessment if there is a fall and to notify the hospice agency. LPA Moleski did not observe any fall risk assessments documented in R1’s file. [continued on 9099-C] LPA Moleski reviewed notes taken by R1’s hospice nurse. The notes indicate that, during a visit on 11/4/24, R1’s RN discovered “several abrasions to right knee and bilateral feet and skin tears and abrasions to left forearm.” According to the note, R1’s RN was told by facility staff that R1 was agitated during the night and was found on the floor. LPA Moleski visited this facility on 11/12/24, after R1 had already died. During the visit, R1’s bed had already been removed, so it was not available for inspection. In an interview, Barias said that R1 was very restless, and their injuries were caused by R1 hitting the side rails on their bed. Barias said that R1 also slid down to the floor from bed. Barias said her staff had put a mattress below the bed, and they also put blankets and pillows on the bed rails to prevent further injuries. Barias said the protective padding was put in place after R1’s first incident of falling on 10/31/24. In an interview, S1 said that R1 was able to remove the blankets and pillows from the rails after staff added them. S1 said that R1 continually banged their hands into the rails, suffering swollen hands, and R1 also kicked the wall next to their bed with their feet. S1 said R1 also scratched themselves on the arms, removing the skin. S2 said that staff could not control R1’s behavior, even after giving R1 their PRN medication, and R1 continued to hit the rails. S2 said that staff used pillows and other padding to cover the rails, but R1 also kicked the wall adjacent to their bed, and suffered a scrape on their foot as a result. S2 said that R1’s hands and fingers were purple from striking the rails, and R1 also hit their head into the rails. S3 said that R1 wasn’t eating, was waving their arms around, and was scratching themselves on the arms. S3 said that when they observed this behavior, they put a pillow on R1’s bed rail, and also put a recliner up against R1’s bed, effectively restraining R1. S3 said that staff were supposed to call R1’s nurse if they became agitated, but they didn’t speak with the nurses because of their lack of English proficiency. In an interview, R1’s RN said that staff should have immediately called the hospice agency to report R1’s behavior. After R1’s RN discovered R1’s injuries on the morning of 11/4/24, R1 received an increase in prescribed medications through the hospice agency. No additional unusual incidents or injuries were noted in R1’s ongoing notes from that time until the time of R1’s death on the night of 11/5/24. In an interview, R1’s RP said that R1 suffered many bruises because they frequently tried to crawl out of bed. R1’s RP said that staff had put a mat on the floor to prevent injury from falls. R1’s RP was not aware of R1’s habit of hitting their bed rails with their hands. R1’s RP said that staff also placed barriers up to prevent R1 from leaving bed, such as a wheelchair placed against the bed, and additional rails on the lower portion of the bed. The use of de facto restraints by staff will be addressed in a follow-up case management report. [continued 9099-C] Based on the above interviews, although some preventative measures were taken by staff to prevent R1’s injury, they were not effective, as R1 was able to remove the blankets and pillows from their bed rails and continued to engage in self-injurious behavior as a result. Additionally, despite suffering numerous falls prior to 11/4/24, fall risk assessments were not documented, and R1’s hospice agency was not notified for follow-up, as required by R1’s hospice care plan. According to a note written by R1’s hospice nurse dated 11/4/24, R1 had been medicated immediately prior to the nurse’s visit, and while reviewing medication logs and doses, inconsistencies were discovered. In an interview, Barias said that, on 11/4/24, a staff member, S1, gave R1 two doses of an antipsychotic medication within two hours, when R1’s medication order indicated it should only be given every four hours. LPA Moleski reviewed R1’s medication administration records (MARs) and confirmed Barias’ statement. R1 was given a 1-millileter dose of the medication at 8 a.m. on 11/4/24, and a second 1-millileter dose at 10 a.m., according to the MARs. R1 was later given 1 milliliter of the same medication at 2 p.m., then 1.5 milliliters at 6 p.m. and 10 p.m. LPA Moleski reviewed R1’s prescription orders. LPA Moleski reviewed a prescription dated 10/21/24, which indicated that R1 could have a maximum of 1 milliliter of the medication every four hours as needed. LPA Moleski reviewed an approved medication list which included the same prescription as of 10/28/24. A new prescription for the same medication was authorized by a hospice agency physician as of 11/4/24 at 11:05 a.m. for a maximum of 1.5 milliliters every four hours as needed. In an interview, S1 admitted that they had given the medication a second time on the morning of 11/4/24 within two hours, rather than four, but said they thought it was the only way to calm R1 down. LPA Moleski reviewed daily progress notes for a resident (R2). A note on 10/23 indicated that R2 was going to the bathroom "too many times." A note on 10/31 states that R2 "stole the raisins and ate half." Another note that same date stated that R2 "try to take stuff fr pantry room, I told him you not suppose to open that, you ask if you want something" [sic]. In an interview, Barias said an incident occurred on 11/4/24 wherein R2 had gone to the bathroom without assistance and was “messing it up.” Barias said they were notified by R1’s hospice agency that a staff member (S1) was yelling at R2 because of this. Barias was not present during this incident, but said S1’s voice is “too loud.” [continued on 9099-C] In an interview, R2 said that S1 is “bossy” and has a “staccato” way of speaking to R2. R2 said that S1 often sends R2 out of the kitchen, except at mealtimes. R2 described S1 as commanding. In an interview, S1 described their own voice as “not that sweet” and “loud.” S1 said that they were not expecting a nurse to be present on 11/4/24 to “observe my attitude.” In an interview, R1’s RP, who was also present on 11/4/24, said the staff member was yelling at R2, and asking R2 why they had made such a mess. R1’s RN, who was present on 11/4/24, confirmed they had also overheard the incident. The department has determined the following as it relates to the allegations that a resident suffered injuries due to staff neglect, that staff did not follow a hospice care plan for a resident, that staff did not notify a resident’s responsible party about a resident’s injuries, that staff did not dispense medication to a resident as prescribed by their physician, and that staff spoke inappropriately to residents: Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87464(f)(1), 87633(a)(4), 87211(a)(1), 87465(a)(4), and 87468.1(a)(1). An exit interview was held with Barias. Appeal rights and a copy of this report were left with Barias.