Complaint·August 4, 2021

Facility staff failed to report resident's change in condition to responsible party. Incident reports indicate that the conservator was notified of falls that took place on 12/21/20 and 12/22/20. Progress notes for 12/21/20, 12/22/20 and 1/28/21 indicate that the conservator was notified of resident (R1’s) falls. Progress notes indicate that a meeting was held on 2/11/21 regarding a possible change in R1’s condition and that there was concern of a potential UTI. On 3/9/21, the facility was informed that the resident had a positive UTI lab result and was prescribed a new medication. According to the progress notes and interview with the Resident Care Coordinator, the conservator was contacted via email on 3/4/21, 3/9/21, 3/10/21, and 3/11/21 regarding an updated care plan after being re-evaluated by facility. The updated care plan does not specify that the resident had a positive UTI. The interviews, emails provided by facility, and progress notes revealed that the conservator was not notified of the resident’s positive UTI lab results. Facility staff did not seek timely medical attention for a resident in care. Progress notes indicate that a telephone conference was held with the conservator on 2/11/21 regarding a possible change in R1's condition and the concern of a potential UTI. Progress notes from 2/12/21 indicate that R1 was seen by a physician, a urinalysis (UA) was ordered, and the UA order was to be faxed to the facility. Progress notes from 2/22/21 notate communication with the conservator and that the conservator wanted to follow-up on UA testing. Facility informed conservator that they did not yet receive the UA order. Progress notes on 2/25/21 indicate that R1 had a doctor’s appointment and facility followed-up on the UA order. On 2/25/21, facility received documentation from All Inclusive Medical Services (AIMS), which specifies "UA culture if indicated". Progress notes from 2/26/21 indicate that a nurse from the facility contacted AIMS to follow-up on the UA order. Progress notes from 3/1/21 indicate that the facility received a new order for UA with culture if indicated and the conservator was notified. According to progress notes dated 3/2/21, the conservator picked up the UA sample from the facility on 3/2/21. The facility had several gaps of communication with the physician and UA clinic between 2/12/21-3/2/21 regarding the UA order. ****************************************************Continued on LIC9099-C************************************************* Resident sustained an injury due to an unwitnessed fall. On 12/21/20, R1 had an unwitnessed fall in one of the hallways of the facility and sustained a pelvic fracture. R1 has a history of fainting spells and facility staff utilize a documentation survey report to indicate when staff assist with R1's daily living needs. According to the documentation survey reports dated December 2020-April 2021, facility staff provided assistance with mobility and any transfer needs during all shifts. Facility staff also contacted emergency services in a timely manner after the fall on 12/21/20 and R1 received medical care. Although the allegation is Substantiated, no deficiencies are being cited for this allegation as the facility followed the needs and services plan and also ensured R1 received appropriate medical attention. Resident was admitted to facility without responsible party's consent. R1 was admitted to the facility on 6/29/20 and family member signed the admission agreement for R1's admission. R1's admission agreement is missing a signature from R1's conservator. R1's conservator signed R1's Care Plan dated 7/1/20, which was 2 days following the admission of R1 to the facility. The facility does not have any documentation indicating that the conservator provided written consent for admission of R1. Conservator documentation indicates "it is ordered that the conservator of the person is authorized to place the conservatee in a secured-perimeter residential care facility for the elderly". The conservator was not included in the admission of R1. Resident was moved to another room without responsible party's consent. Progress notes from 3/12/21 indicate that the facility contacted the conservator via email to inform them that the facility was to begin day programming for R1 in the Reminiscence (REM) neighborhood. Progress notes from 3/26/21 indicate that the facility staff spoke with the conservator to report that they are ready to move R1 to the REM neighborhood. The facility moved R1 to the REM neighborhood on 4/2/21. R1 has a diagnosis of Dementia and conservator of care. A 30-day written notice is required for any room changes unless the resident agrees to the room change. R1's conservator would be responsible for agreeing to any room changes for R1. The facility did not have any documentation indicating that a 30-day written notice was provided to R1's conservator regarding R1 moving to a new room on the second floor in REM. Based on interviews conducted 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 9099D. An exit interview was conducted with the Executive Director and a copy of this report. Appeal rights were provided. Facility staff failed to observe resident's change in condition Progress notes indicate that a telephone conference was held with the conservator on 2/11/21 regarding potential elimination of resident (R1) utilizing 1:1 companionship care from an outside resource. Progress notes for 2/11/21 indicate that there was concern with R1 having a potential change in condition that was recognized by the 1:1 companion. Progress Notes indicate that, during the phone conference on 2/11/21, there was discussion regarding the conservator being informed by the 1:1 companion that R1 was agitated in the mornings, which was not R1’s baseline. However, facility staff were not informed by the 1:1 companion of R1’s behavior. Progress notes indicate that R1 can get agitated and refuse assistance from staff frequently. The day after the telephone conference conducted on 2/11/21, R1 was seen by a physician regarding a potential UTI. According to interviews with the Executive Director and Residential Care Coordinator, R1 has a history of UTIs. There were no notations in any of R1’s progress notes indicating that facility staff had noticed a change in R1’s condition. Based on interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited during this visit. Exit interview conducted.