complaint·June 25, 2021

9099C(1).. Resident's physician's report , dated 11/6/2019, notes resident has a diagnosis of Dementia and Seroquel was prescribed to control agitation and aggressive/forceful behaviors. Appraisal dated 11/15/19 notes that resident can be unstable walking, if taking calming medications, calming medications may need to be adjusted/changed, and resident needs special observation/night supervision due to being confused/forgetful/wandering due to Dementia diagnosis. Stability Risk Assessment Form dated 11/20/2019 indicates that resident has balance problems with walking and has had no history of falls in the last 12 months. Care Plans dated 3/18/2020, 12/12/2019 and 11/26/2019 note that resident has a potential for falls and requires observation from staff for safety needs. Care plan dated 12/12/2019 notes that resident needs special observation at night when resident gets up to use the bathroom. Interview with one staff indicated that resident did not have a 1:1 but could have used one during the daytime hours, as resident became less stable on his feet and was observed to have fallen more than once on a shift. Another staff stated that resident would get up and wander during the night and needed 1:1 supervision to prevent falls. Hospital medical records note that resident's representative indicated to a hospital social worker that resident had a 1:1 caregiver when he first moved to the facility in November 2019 until the Covid19 lock down began, in March 2020. Health and Safety Director stated that resident became more agitated , didn't want to be bothered and was walking a lot more than when he first moved in and wasn't sure if this change was documented in resident's file. Care Director indicated resident was a fall risk and "scooted his feet to walk" and staff tried to keep resident in the common area and checked hourly on him. Care Director added that resident had a few falls, about twice a week, so resident's medications were changed . Health and Services Director stated resident had an "unsteady gate" and would wander everywhere but was in sight every hour within the memory care unit. Charting notes reflect resident had (5) falls on 1/13/2020, 4/4/2020, 5/14/2020, 5/23/2020 and on 5/26/2020 and was sent out for further medical evaluation on 5/23/2020 and 5/26/2020. Notes and LIC624 received reflect resident was showing increased agitation and combativeness on 5/10/2020 when resident tried to hit a staff member, and inadvertently hit another resident. On 5/15/2020, notes document facility nurse had, a phone appointment with resident's physician and it was discussed that the prescription for Alprazolam (Xanax) .25 mg would be increased from one-half tablet , 3 times per day, to one tablet 3 times per day. MAR for May 2020 shows Alprazolam (Xanax) .25 mg tablet was prescribed to be administered 3x/day effective 5/15/2020 (8:00 pm), as a routine PRN medication, and then prescribed as a scheduled medication effective 5/16/2020 and was administered through 5/26/2020 (8:00 pm). cont on 9099C(2).. . 9099C(2)...with meeting with resident's representative to discuss "increasingly aggressive behaviors" and later that day, notes indicate Regional Health Services Director e-mailed resident's representative regarding a recommendation from facility's Regional Health Services Consultant to request a referral from resident's physician for a mental health behavioral modification. Charting notes show that a new order for Quetiapine Fumarate (Seroquel) 25 mg was discussed and received on 5/21/2020 , prescribing one tablet up to 3 time per da y for agitation and a follow up prescription was received for the same medication on 5/25/2020 , to be taken 3 times per day for agitation. MAR documentation shows Quetiapine Fumarate (Seroquel) 25 mg, one tablet per day was started on 5/24/2020 at 8:00 am and given through 5/26/2020 (8:00 pm), when resident was sent out to the emergency room following a fall that night. In addition to the scheduled medications, resident was administered PRN medication Alprazolam (Xanax) .25 mg for agitation on 10 days in May 2020, including on 5/14/2020, 5/23/2020 and 5/26/2020, when resident fell. Additionally, resident was taking the medication Donepezil 5mg, 1 tablet per day from 1/7/2020- 5/26/2020. MAR documentation lists side effects of drowsiness and dizziness for medications, Donepzeil, Alprazolam and Quetiapine. Resident fell on 5/14/2020, 5/23/2020 and on 5/26/2020 and the injuries were more severe with each subsequent fall. Staff training records were reviewed for (1) caregiver (S2) and (2) med-techs (S3/S4) who regularly assisted resident, including on 5/26/2020, with care and/or administering medication. Record review showed there was no documentation that S2, S3 and S4 had received training on the effects of medications given to treat behaviors associated with Dementia. LPA also reviewed training documentation, provided in March 2021, for caregiver (S1) who works in assisted living, which showed that caregiver last received training in psychotropic medications in December 2019. (See separate 809 for citation). LIC 624 dated 5/23/2020 notes that when resident was walking around in another resident's room, lost his balance and fell, hitting his head on the corner of the wall, sustaining a bump and small abrasion on the back of his head. EMS report dated 5/23/2020 (10:44 am) note that resident had "previous abrasions to both arms noticed from previous falls. Resident is combative and tried to bite" and refused neck collar. LIC624 states that resident returned to the community the same day at approximately 5:30 pm with no new medication orders received. cont on 9099C(3)... 9099C(3)...Charting notes and LIC624 both document that resident fell on 5/26/2020 in his room when a noise was heard coming from resident's room at approximately 10:45 pm. Upon responding, caregiver (S2) found resident on the floor with his head under the TV stand, bleeding from the head and right eye and immediately called Med-Tech (S4 ) on her walkie. Interview with Med-Tech (S3) stated she checked on resident at approximately 9:45 on 5/26/2020 and resident was sleeping in his bed. Motion sensor records document motion in resident's room on 5/26/2020 at 8:01 pm, 9:36 pm, 10:35 pm and at 10:51 pm. Emergency Medical Services (EMS) report for 5/26/2020 shows that they were contacted by the facility at 10:48 pm (22:48), arrived on site at 10:59 pm (22:59) and resident's room at 11:02 pm (23:02). EMS documentation also notes that "Staff stated resident had fallen twice earlier the same day. Staff stated resident is usually agitated and combative w/staff." Resident was admitted to the hospital for a cerebral bleed and was discharged on hospice on 5/28/2020 and returned to his home, before passing on 5/31/2020. Hospital records dated 5/26/20 show "Internal development of scattered extensive intraparenchymal hemorrhage across the bilateral cerebral hemispheres involving all lobes to variable degrees with greatest involvement of the left frontal and temporal lobes", or "bleeding in the soft tissue of the brain," as explained by the attending emergency room physician in an interview with the department and who also confirmed that resident's injuries were consistent with a ground level fall. County Death Certificate notes that resident passed on 5/31/20 and the immediate cause of death was: Alzheimer's Disease . Coroner records document that resident sustained an injury from an unwitnessed fall on 5/26/2020 from care facility, and the manner of death was an accident. Facility internal incident reports completed by staff for incidents occurring on 5/23/2020 and 5/26/2020 indicate that facility contacted an alternative ambulance medical services instead of 911 for resident to obtain a further medical evaluation. A citation was previously issued on 2/16/2021 and facility completed follow up in-service training. cont on 9099C(4).. 9099C(4)... 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 (1) deficiency is cited. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Exit interview. Copy of report and appeal rights provided.