Inspector’s narrative
What the inspector wrote
Due to conflicting information received, it could not be determined that facility staff neglected R1 resulting in R1 sustaining rashes while in care, therefore, the allegation is Unsubstantiated.
An Unsubstantiated finding means that 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.
An exit interview was conducted where reports (LIC 9099 & LIC9099-C) were discussed, and a copy was provided to Administrator Woofter at the conclusion of the visit.
The facility’s policy regarding falls indicated the staff should not have attempted to move the resident, but instead either summoned emergency medical services (i.e., call 911), or contact the physician for further instructions. The facility staff who assisted R1 after the unwitnessed fall helped R1 off the floor and escorted R1 back to bedroom, which was not in accordance with the facility’s policy for falls. Facility staff stated during investigation that R1 denied having pain when asked. However, records review indicated that R1’s primary diagnosis was Dementia (loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). It is not known if R1 was able to have understood or have been able to verbalize the presence and location of pain. Facility staff also reported that R1 “looked confused” following the incident.
On 8/14/2022, at approximately 7:00–7:30 am, R1 was observed with skin tears, blood on pajamas near elbows, signs of pain and unable to sit up. On the same day around 11:30 am, R1 was admitted to the local hospital. According to medical records, R1 had had a lumbar compression fracture, a mildly displaced left femoral intertrochanteric fracture, and skin tears on both elbows. Medical records also indicate the cause of the injuries was an accidental fall. Additional records review found that the facility’s admission agreement indicated, “This is a non-medical care facility that does not and cannot provide medical, intermediate or skilled nursing care.” In addition, “the following basic services will be provided “Monitoring and appropriate reporting of resident needs and condition to family and physician.” It is unknown what additional change of condition occurred with R1 during the time of the fall until medical care was sought.
R1 passed away on 8/16/2022. R1’s Certificate of Death indicated the immediate cause of death was cardiopulmonary arrest (also known as cardiac arrest when the heart s
tops pumping blood and breathing stops) and Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) as the underlying cause. Also, other significant conditions contributing to death were left hip fracture, and L-1 (lumbar, part of the spine, and first bone of the five lower back bones) compression fracture.
Based on the investigation, the allegation that facility staff
did not seek medical attention in a timely manner for resident
is Substantiated.
A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met
.
R
egarding the allegation, neglect/lack of care and supervision resulting in resident sustaining multiple injuries, investigation reveals that on 8/13/2022, facility staff left R1 unattended sitting at the dining table for an unknown period of time. R1 had an unwitnessed fall. Staff returned to the dining room on or around 4:30 pm and found R1 on the tile floor near a door. Staff assessed R1 and transported R1 back to R1 bedroom and put R1 in bed. Emergency services were not contacted for R1 on day of fall. After the fall, R1 did not receive medical care and services until 8/14/2022. In addition, neither R1’s responsible party nor physician were immediately notified by the facility after the unwitnessed fall. Interview and records reveal that R1 had a previous fall in October 2020 and per facility staff, R1’s ability to walk and function with minimal assistance had declined. Facility record review reveals, R1 had primary diagnosis of dementia. In addition, per Physician’s Report, dated 6/03/2021, R1 assessment included but was not limited to indication that R1 was unable to ambulate without assistance, experienced dizziness, was confused/disoriented at times with sundowning behavior (a state of confusion that occurs in the late afternoon and lasts into the night causing various behaviors, such as confusion, anxiety, aggression or ignoring directions, and can lead to pacing or wandering) due to dementia, and required assistance with medication management and daily self-care, including feeding self. R1 also had a visual impairment, glaucoma, (an eye condition that can cause vision loss) of the left eye.
During investigation, a facility caregiver stated that R1 “required a walker but refused or forgot to use it.” Two caregivers also stated that R1 required assistance to the dining area by physically holding R1 hand/arm and walking near or next to R1 because R1 was weak and at risk of falling. In addition, R1 was at risk of choking, yet R1 was left unattended in dining room with food in front of R1.
In addition, facility admission agreement for R1 indicates that basic services such as “Assistance with activities of daily living: care and supervision which includes assistance with medication, dressing, toileting, bathing, grooming, mobility, telephoning, and correspondence; central storing and distribution of medication will be provided."
Based on the investigation, the allegation of neglect/lack of care and supervision resulting in resident sustaining multiple injuries (fractures) is Substantiated. A substantiated finding means that the allegation is valid because the preponderance of e
vidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The Administrator was also informed that an enhanced civil penalty may be assessed based on Health and Safety Code § 1569.49
Regarding the allegation,
Neglect/lack of care and supervision resulting in resident sustaining skin tears, investigation reveals on 8/13/2022,
R1 was observed with skin tears, blood on pajamas near elbows, signs of pain and unable to sit up. On the same day around 11:30 am, R1 was admitted to the local hospital. According to medical records, R1 had had a lumbar compression fracture, a mildly displaced left femoral intertrochanteric fracture, and skin tears on both elbows. Medical records also indicate the cause of the injuries was an accidental fall.
R1 fell while in care and sustained skin tears on the elbows. Staff denied seeing the skin tears the night before when they conducted a body check after the fall. Staff did not call 911, family, or a supervisor to report the fall.
Based on the investigation, the allegation of neglect/lack of care and supervision resulting in resident sustaining skin tears is Substantiated. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met.
Regarding the allegation, facility staff did not inform authorized representative of resident's injuries, the investigation reveals that on 8/13/2022, R1 had an unwitnessed fall. Staff found R1 on the tile floor of the dining room.
Staff assessed R1 and transported R1 back to R1's bedroom and put R1 in bed. At the time of the fall (incident), it was found that R1 had been left unattended. Emergency services were not contacted for R1 on the day of the fall. Neither R1’s responsible party nor physician were immediately notified by the facility after the unwitnessed fall. In addition, facility staff revealed that night shift was not informed that R1 had an unwitnessed fall during the day.
On 8/14/2022, R1 was observed with skin tears, blood on pajamas near elbows, signs of pain and unable to sit up. On the same day around 11:30 am, R1 was admitted to the local hospital.
According to medical records, R1 had had a lumbar compression fracture, a mildly displaced left femoral intertrochanteric fracture, and skin tears on both elbows.
Review of facility's admissions agreement reveals basic services includes, "monitoring and appropriate reporting of resident needs and conditions to family and physician."
On 8/15/2022, staff received disciplinary counseling for not reporting R1’s fall to family, appropriate supervisor, and not following facility’s fall policy to call 911 emergency services. An incident report dated 8/15/2022 shows R1 had an unwitnessed fall in the dining room but did not include signs of pain or injuries.
Based on this investigation, the allegation of facility staff did not inform authorized representative of resident's injuries is Substantiated. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met.
An exit interview was conducted where reports (LIC9099-A, LIC9099-C, LIC9099-D, LIC421M) where discussed and provided with appeal rights to Administrator Woofter at the conclusion of the visit.
