complaint·July 24, 2024

9099C-1.. Resident's care plan, dated 3/5/24, notes says resident is “weak and confused” and “planned an escape from previous facility before arriving”. Care plan says resident has a “history of confusion and wants to leave, having some outbursts”. Watch resident and work with hospice if he has any outbursts. Allegation: Resident was left on the floor unassisted after sustaining a fall for an extended period of time due to staff neglect. Allegation states resident (R1) was left on the floor after falling for more than 2 hours, on 3/19/24. Administrator, Robert Tif, stated on 4/10/24 to LPA Angela Hood that (R1) slid off the bed and refused to get up , didn't want staff to assist, and he wanted to stay on the floor, stating resident was cooperative only at times. Resident facility notes indicate that on 3/19/24, resident slid down from his bed and refused help from (3) caregivers. Caregiver (S1) stated she "checked on (R1) at 7:00 am, and he was still sleeping" but by 9:00 am, he was on the floor, asserting, "he did not fall- he slid off his bed". (S1) stated that she and another staff were trying to get (R1) up from the floor, but "we couldn't get him up- he was kicking staff". (S1) stated that even hospice nurses couldn't provide care for (R1) and one night, the nurse was at the care home until midnight observing (R1')s behaviors and was unable to provide care at some times. Hospice notes show the nurse stayed for (6) hours on 3/19/24, from 6:00 pm until 12:00 am, observing resident and administering a new medication. Another staff (S2), who worked during the day, was interviewed but stated she was not at this facility at the time of this incident, but that another care staff, went to assist (S1) from the adjacent related facility, with (R1). (S2) indicated she no longer works at the care homes. Hospice notes document on 3/19/24 (12:06 pm) - a Home Health Aide (HHA) from hospice arrived and resident was “found on the ground, bleeding on the right arm and covered in urine”. Notes stated care staff indicated (R1) had been on the floor since the morning, the HHA and the caregiver were able to put (R1) back in bed, but (R1) was observed to have redness on right hip, new skin tears, and a missing a toe nail. (R1's) condition was reported to an Registered Nurse, who would provide follow up care later that day. Hospice notes document that (R1) received a complete bed bath and ADL care. *cont on 9099C-2... 9099C2... Three (3) photos were viewed that were taken by hospice on 3/19/24 (12:06 pm) showing (R1) on the floor. One photo shows (R1)laying on the floor in his room with blood near the right arm where he was laying. Clothes appear soaked, and hospice notes say resident was "soaked in urine". The photo shows resident's catheter attached laying on the floor. The second photo shows (R1) was found wearing a soiled diaper when the nurse arrived. The third photo shows redness on (R1's) right hip, as stated in hospice notes. Hospice notes show that on 3/19/24 (2:15 pm) a nurse arrived to provide catheter care and (R1) became very agitated and would not let go of the nurse's wrist for a couple of minutes. The nurse obtained a physician's order for the medication Haldol. Notes show that another nurse arrived on 3/19/24 (3:15 pm) to administer Haldol and monitor resident who was displaying restlessness, agitation, and episodes of hallucinations. A continuous care nurse arrived around 6:00 pm to continue monitoring (R1), who continued to show agitation, disorientation and attempts to stand up. Another dose of medication was given around 7:00 pm, and again at 11:00 pm, before (R1) relaxed and went to sleep, at which time the nurse left. Both the resident's family member and hospice stated the facility did not call them, and they were not aware of (R1) being on the floor, for over 2 hours, until the hospice home health aide arrived for a scheduled appointment to provide assistance with Activities of Daily Living (ADL's). Based on information obtained, LPA 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: Staff do not provide resident adequate supervision resulting in resident wandering outside. The allegation states resident (R1) had to be retrieved from outdoors unaccompanied at night, and was found in the garage, without any clothes on on another occasion. Staff (S1) stated she found (R1) around 9:00 am, "squatting in the garage with a diaper on only", and she has "no idea" how long (R1) was in the garage. (S1) confirmed that the large garage door was open and that she "doesn't know how it opened or how (R1) got to the garage". (S1) confirmed she brought (R1) into the house upon discovering him there and it was only one time he was found in the garage. Staff (S2) stated she remembers when (R1) was found in the garage one morning and stated "he always wanted to leave, especially when his daughter visited- he would get agitated sometimes". *cont on 9099C-3.. 9099C-3... Resident's family member stated she was called following when (R1) was found in the garage on the morning of 3/15/24, and his "arms were torn up, he was naked and his catheter was torn out". The family member stated (S1) called hospice upon finding (R1) in the garage and hospice came out and observed wounds from his wrist to his elbow that were "bad" and had to be wrapped completely. Resident's family member stated (S1) showed her a picture she had taken of (R1) sitting on blankets by the laundry machine in the garage. Hospice notes from 3/15/24 (10:09 am ) state the hospice RN received a phone call from the facility needing a nurse to come by, and upon the nurse’s arrival, the caregiver stated (R1) was found sleeping in the garage, with no clothes on, and (R1) had disconnected catheter bag again and there was blood to both arms from skin trauma (picking scabs). Notes state that (R1) allowed the nurse to perform wound care while being “confused and drowsy”. Also included in the hospice notes, is that (R1) was allowed to depart from an unlocked door in his bedroom, and the owner was contacted and advised that “dead bolt must be locked to prevent injury/escape by resident who is highly confused”. A new Seroquel prescription arrived and was administered . The facility Administrator stated on 7/24/24 that the current door alarm was on the exit door from (R1's) room but he is not sure if it was working to alert the NOC shift. LPA observed the alarm on the door today to not be activated, but the room is currently vacant. Facility notes document that on 3/9/24- (R1) “got up on his feet by himself- caregivers surprised he can walk so well”. Notes document on 3/10/24 (R1) had wandered from his room and was found in the living room by caregivers. Notes entered on 3/11/24, stated that (R1) was doing "more wandering" in his room and bed alarms were placed in his room to better monitor him. Notes entered on 3/13/24, state (R1) is more calm, seems to be getting acclimated to home and getting a little stronger. There was no time of day indicated in the notes for the above days. Facility notes document on 3/14/24, (R1) wandered into the garage at 5:00 am, was brought back to his room, and family was called. On 3/15/24, no notes were made that resident was found on the floor in the garage, with only a brief on and multiple bleeding wounds on the arms. *cont on 9099C-4... 9099C-4... Resident's family member stated that she recalls from her conversations with both facility and hospice staff, that (R1) was able to make his way to the garage on two separate occasions and stated, "It was too much for one caregiver to handle (R1) and the other residents- (R1) needed more attention and needed to be checked on more frequently". Staff (S3) who works during the night shift (7 pm- 7 am) was not available for an interview. Based on information obtained, LPA 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: Staff do not ensure that resident's incontinence needs are being met. Allegation states resident (R1) was left in soiled briefs for prolonged periods. The Administrator confirmed "yes, we tried to change him- sometimes he would be cooperative and sometimes he would not" and (R1) had a catheter that hospice was providing care for. Hospice notes on 3/15/24 (9:42 pm) document the on-call nurse received a call from the facility that "no urine had drained into patient's collection bag since it was replaced on this morning". Both hospice staff and (R1's) family member stated that caregivers were informed to notify hospice if there is no urine output within 2-4 hours of the bag being changed. Hospice care notes entered on 3/19- (12:06 pm) by a Home Health aide, document (R1) was “found on the ground, bleeding on the right arm and covered in urine ”. Care staff stated (R1) had been on the floor since the morning. The Department reviewed a photo showing the soiled diaper (R1) that was found wearing during this HHA's scheduled visit, on 3/19/24, to provide ADL care. A hospice nurse confirmed the soiled diaper shown in the photo was not blood or urine, but feces . Also provided was second photo showing (R1) laying on the floor in his room, with soiled clothing and the catheter bag and tubing on the floor. Hospice notes match the photos provided. Based on information obtained, LPA 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 (3) deficiencies are issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided.