complaint·August 16, 2023

Allegation: Staff did not provide proper medication assistance to resident in care. – Unsubstantiated. According to complainant, R1 became a resident at Brookdale Folsom in the memory care unit in August 2022. On three occasions R1 was found over medicated that R1 was barely breathing and was unable to walk, talk, eat, or drink. Complainant concerns is that staff were giving R1 narcotics such as Morphine with no clear idea of drug indications and side effects. The Department requested and reviewed R1’s physician’s report. Physician’s report indicates R1 is unable to administer own prescription medications, administer own injections, perform own glucose testing, administer own PRN medications, administer own oxygen, and store own medications. R1 is on hospice. According to R1’s doctor’s orders, R1 was prescribed Morphine Sulfate oral solution 10 MG/ML to give R1 0.5 ml by mouth every 1 hours as needed for pain/sob. The Department interviewed a total of six (6) staff. Interview statements received from staff (S1) indicated, R1 is on hospice and was prescribed Morphine for pain. S1 stated facility’s procedure before providing R1 with Morphine, the facility would call and notify R1’s responsible party (RP) to get an approval. The facility will not provide Morphine without calling hospice for their advice and recommendations. Interview statement received from Resident Care Director (RCD) indicated, the facility was in constant communication with R1’s RP regarding medications such as Morphine. RCD stated when R1 was placed on hospice R1 will clearly notify staff that they were having back and hip pain. R1 was starting to decline, and staff would often hear R1 groaning in pain and would continuously shift positions to indicate she was in pain or uncomfortable. Interview statement received from S3 and S4 indicated, R1 is not able to request for specific medication, however, R1 is able to notify staff that R1 is in pain. After R1 would notify staff of their pain, staff would then notify Med Techs. The Department received interview statement from R1’s hospice nurse. Hospice nurse indicated, R1 can request for Morphine sometimes. R1 was able to make R1’s needs known. Hospice nurse explained that the facility would give R1 Morphine in the middle of the night and then R1 would subsequently be out of it the next morning. Hospice nurse stated they were not there when the facility medicated R1. The facility has given R1 morphine due to shortness of breath or for pain. Hospice nurse indicated there is not a lot of times that R1 was in pain that the nurse knew of. Hospice nurse indicated, the facility is required to notify R1’s RP and hospice when giving Morphine to R1. The Department reviewed R1’s medication lists and the MAR. Facility is correctly using the MAR and found no discrepancies. Allegation: Resident sustained multiple falls while in care. – Unsubstantiated. According to complainant, during R1’s stay at the facility R1 experienced at least 6 falls causing physical and emotional trauma which accelerated R1’s existing Dementia. The last fall occurred because an aid left R1 unattended on the toilet resulting in R1 falling forward onto R1’s forehead and arms. According to R1’s physician’s report that was completed on 7/15/2022, R1 can bathe self, dress/groom self, feed self, and care for own toileting needs. R1 is ambulatory. According to R1’s service plan completed on 9/14/2022, R1 can perform the following showering tasks with physical assistance as needed, washing lower body. R1’s showers schedules are on Monday and Thursday. R1 needs help in the bathroom with pulling pants up and down, assist with handling toilet paper and wiping from front to back. Assist with changing protective undergarments. R1 is incontinence of bladder. Manage R1’s incontinence product. Facility is to provide physical assistance to and from the dining room and or community activities as needed. R1 has falling in the last 12 months. R1 uses a walker as mobility aid. According to R1’s progress notes, R1 had a total of six (6) unwitnessed falls. All unwitnessed falls were reported to R1’s RP. R1 was sent out to the hospital for an evaluation. The facility notified R1’s hospice nurse of all unwitnessed falls. Interview statement received from R1’ hospice nurse indicated, R1 was able to walk and talk at the beginning and had declined significantly. Hospice nurse stated they were not there to observe any of R1’s fall incidents that occurred at the facility. Interview statement received from S3 indicated, R1 is a fall risk. R1 had multiple falls. The facility had implemented a fall plan for R1. Staff is to conduct rounds to check on R1 every 30 minutes. S3 stated when a resident in the memory care unit has an unwitnessed fall the facility will call 911. EMT would come out to assess resident and check vitals. EMT will then transfer resident to the hospital for an evaluation. The facility will then call resident’s responsible party to notify them of the incident. S3 explained if a hospice resident had a fall the facility will call and notify hospice. Hospice will then send their nurses out to evaluate the resident. According to R1’s progress notes, all unwitnessed falls were reported. The facility did their due diligence after each unwitnessed fall. R1 was sent out to the hospital for an evaluation. Allegation: Staff left resident unattended. – Unsubstantiated. According to complainant, an aid left R1 unattended on the toileting resulting in a fall. Interview statement received from ED indicated, a staff was assisting R1 in the bathroom and an exit door alarm went on. R1’s bedroom is located near the exit door. Staff went to check if there were any residents that tried to leave the community and returned to assist R1 in less than a minute. ED stated when staff returned R1 was still on the toilet and there was no fall incident when that occurred. Interview statement received from 5 staff indicated R1 is a fall risk and staff are to conduct frequent rounds to check on R1. Interview with 5 staff indicated, they were not working when this incident occurred and was not aware of that incident at all. Interview received from R1’s hospice nurse indicated, during visits there are always staff there with residents in the memory care unit. The Department could not find enough evidence to confirm nor deny this allegation happened. The Department finds this allegation to be UNSUBSTANTIATED - meaning 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. No deficiencies being cited for today’s visit. Exit interview conducted and report left at the facility.