Inspector’s narrative
What the inspector wrote
Licensing Program Analyst’s (LPAs) Carmen Lopez and Ryan Fulton conducted an unannounced Case Management visit to cite deficiencies from a previous visit on May 6, 2020. LPA was greeted at the front door by Edgar Baltazar, Lead Concierge and granted entry after identifying themselves and disclosing the purpose of their visit. LPA discussed the purpose of the visit with Ada Navarrete, Director of Resident Care, Kristiana Lopez, Business Services Office Manager/Human Resource Manager, Joan Rink-Carroll, Director.
The facility submitted an Unusual Incident Report on April 27, 2020, advising that on or about April 20, 2020, at approximately 9:50am, Resident #1 (R1) had an unwitnessed fall and was found face down on the floor. According to the report, R1 sustained a skin tear above the right eyebrow and had a complaint of pain to the right shoulder.
R1 was admitted to Silvergate San Marcos Retirement Residence in October of 2017, to the Independent Living side of the facility and lived alone. Facility records revealed a fall risk assessment was completed, and that a score of 4 or more is at risk for falling. R1 was at a total of 2. R1’s Preplacement Appraisal dated October 17, 2017, listed no health or physical disabilities. R1 was able to ambulate, follow instructions, communicate their needs, complete all activities of daily living independently and leave the facility unassisted.
Facility Physician’s Report dated February 6, 2020 stated that R1 had a diagnosis of congestive heart failure (CHF), hypertension (HTN), hyperlipidemia, aortic valve disorder, orthostatic hypotension, iron deficiency and anxiety.
Interviews with staff revealed that R1 began having falls without injury. The facility staff spoke with family and agreed to move R1 to the Assisted Living side of the facility so that staff could keep a closer eye on the resident.
R1 continued to have falls, one of which resulted in hospitalization. According to facility records and their updated fall risk assessment dated February 5, 2020, a score of 4 or more was considered at risk for falling. R1’s total score was 12, indicating they were a high risk for falls. Although the facility deemed R1 a high risk, facility records revealed that they did not implement all of their own plan to help minimize the risk of falls. According to facility records, R1’s Safety Awareness Tips to Minimize the Risk of Falls, R1 did not have a bed in a low position, a bed alarm or a floor pad.
On April 22, 2019, R1 had been taken to the emergency room after a fall and received a new diagnosis of traumatic injury of head and a contusion to their right elbow. R1 was now ambulating with a walker. Interviews with staff revealed that a new care plan was developed and R1 was encouraged to call for assistance with bathing, dressing, toileting and getting up to prevent future falls. Staff stated they checked on the resident every one to two hours because R1 had dementia and would forget to call for assistance. However, the facility was unable to provide documentation of these checks, including dates and times.
According to facility records, on February 3, 2020, R1 was transferred to the Memory Care Unit, despite their most recent Physician’s Report dated February 6, 2020, had no mention of a diagnosis dementia or mild cognitive impairment.
Interviews with staff revealed that on February 18, 2020, R1 stood up to walk and fell. R1 was sent to the hospital but did not sustain injury and was discharged back to the facility the same day. On the same day, February 18, 2020, based on interviews and the facility’s Unusual Incident Report, at approximately 1:30pm, care staff heard a loud thump in R1’s room and found R1 lying on the floor. R1 stood up to walk and fell. R1 verbalized that they hit their head and complained of back pain. R1 was transported to the hospital via ambulance and the report stated that staff would continue to monitor the resident upon their return. Interviews conducted with staff revealed that staff state they checked on the resident every 10 minutes, however there was no log of dates and times to verify when those checks were being made.
On February 27, 2020, the facility updated R1’s Physician’s Report. The report indicates a diagnosis of ES diastolic heart failure, FTN, hyperlipidemia and anemia. The Physician’s Report makes no indication that R1 is a fall risk, or that they have suffered a traumatic injury to the head, have any cognitive impairment or dementia. R1 is still able to follow instructions and communicate needs, however they are no longer able to leave the facility unassisted.
Interviews with staff revealed that on March 22, 2020, R1 had another fall with no injury. On April 5, 2020, R1 had an additional fall with no injury. Facility records did not indicate a change in condition and the facility staff did not conduct a reappraisal. No records were kept of dates and times of when the frequent checks were being made or any update to the resident’s fall plan.
On April 20, 2020, at 9:50am, the care staff was assisting another resident when they heard R1 in their room. Staff was not able to provide the time when they last checked on R1, but when they walked into R1’s room, they found R1 laying on the floor, face down, bleeding from the head with a skin tear on the right eyebrow and a complaint of pain to their right shoulder. R1 was bleeding so severely from their head, S1 had to change R1’s shirt. S1 treated the wound with a cold compress and bandage.
After tending to R1’s wounds from the fall, S1 put R1 into a wheelchair, and rolled them into the dining room, and provided R1 breakfast. Although the resident had a history of frequent, reoccurring falls and a previous diagnosis of traumatic injury of the head, (also noted on the Unusual Incident Report dated April 27, 2020), interviews revealed that staff did not call 911, but instead left R1 in the dining room from 9:30am to 11:40am. Interviews with staff confirmed that the facility has a 911 policy for unwitnessed falls involving injury, yet staff waited over two (2) hours to make that 911 call. R1 was not sent out to the hospital until an outside source medical professional arrived for an unrelated visit and evaluated the resident.
Lastly, outside source records revealed that R1 sustained a large hematoma on the side of their head, requiring stitches. Outside source records revealed that R1 succumbed to their injuries on April 21, 2020. The County of San Diego’s Death Certificate lists the cause of death as acute subdural hematoma and blunt head trauma caused by R1’s fall from April 20, 2020.
Based on interviews and documentation collected from facility and outside source records, deficiencies are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8, on the attached LIC9099D. A civil penalty in the amount of $500 was assessed per Health & Safety code 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1. Determination of Civil Penalties under Health & Safety code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division.
An exit interview was conducted with Ada Navarrete, Director of Resident Care, Kristiana Lopez, Business Services Office Manager/Human Resource Manager, and Joan Rink-Carroll, Director . A copy of this report, LIC 421IM – Civil Penalty Assessment Form, LIC 811 Confidential Names, along with the Licensee/Appeal Rights (LIC9058 03/22) were provided to the licensee during the visit. Signature below confirms receipt of these rights.
