Complaint·April 21, 2023

(Continue from LIC9099) The physician prescribed a full course of antibiotic treatment and R1 returned to the facility. An ankle x-ray was also ordered to evaluate for possible osteomyelitis, (infection in the bone). During a visit conducted on March 20, 2023, it was observed that R1 received wound care by a licensed vocational nurse (LVN). According the LVN, the pressure injury was healing and R1 would continue to receive wound care by the LVN three (3) times per week. On April 17, 2023, during another visit at the facility, it was observed that R1 received wound care by the LVN. According to the LVN, the pressure injury had already improved to a level 2. During staff interviews, it was indicated that on or about Tuesday February 28th and on Thursday, March 2, 2023, staff informed facility management that R1’s right ankle appeared with red discoloration and had a small size “pimple”. Staff also indicated they had noticed stains on the bed sheets and informed facility management. Staff maintained during interviews they did not know the source of the stains because the ankle condition did not appear to be draining and assumed the stains on the sheets were due to other liquid spills. Staff were instructed by management to clean ankle with saline solution, change socks daily and reposition ankle periodically. During an interview, facility management indicated they did not seek additional medical attention because R1 was already receiving medical care by a third-party medical provider at the facility. Based on the evidence obtained during the investigation, licensee did not arrange for medical care as appropriate to treat R1’s observed medical condition as required by Title 22 regulations. It was also alleged that staff did not follow resident’s care plan. Detailed review of R1’s service plan indicated that R1 had a high risk of skin impairments related to bed bound status. The service plan indicated that staff were required to check R1 for comfort and reposition every two (2) hours. In addition, staff were required to check R1’s bodily pressure points and to assess skin integrity daily as needed. The coordination of care agreement between the facility and the medical provider indicated that facility staff were responsible for contacting R1’s medical provider with any needs, concerns, or changes in condition. R1’s care plan also required facility staff to review resident’s status on an ongoing basis with the medical care team and to notify the care team of changes in R1’s status. During interviews, staff indicated they informed facility management when they became aware R1’s ankle was red and had a “pimple”. Staff also informed facility management when R1’s bed sheets were observed to have stains of what appeared to be bodily fluids. During interviews, licensee did not provide additional details and testimony was inconclusive. (Continue on LIC9099C) (Continue from LIC9099C) Based on the information obtained during interviews with staff and outside sources it was determined that licensee did not coordinate medical care as the care plan required when R1 experienced a change in condition. It was also alleged that staff did not administer medication as prescribed. On March 20, 2023, during a visit at the facility a detailed review of R1’s medication administration records disclosed that several medications were not administered per doctor's orders. Acetaminophen was ordered as needed for pain, Lorazepam was ordered as needed for anxiety, and Risperidone was ordered as needed for agitation. All three medications were not administered to R1 from February 1, 2023, to March 20, 2023. Observations determined the medicine bubble packs contained all the medication. During staff interviews, it was indicated that medications were not administered as prescribed because an outside source did not allow staff to give the medications. As a result, according to staff, R1 did not sleep through the night and was restless during the day. In addition, staff indicated R1 often showed symptoms of anxiety and agitation which made it difficult to provide care. Based on observations, staff interviews and records review there was sufficient evidence to support the allegation that staff did not administer medications in accordance with doctor's orders. Lastly, it was alleged that staff did not notify resident's authorized representative of a change in condition. It was specifically alleged that staff did not notify responsible party when R1 had a pressure injury on ankle. During interviews, staff consistently stated they informed facility management of R1’s change in condition when they observed the ankle with red skin discoloration. Facility management indicated they did not notify R1’s responsible party. According to facility management, the responsible party used to visit on a daily basis and provided care to R1, so they assumed R1’s responsible party was aware of the ankle pressure injury. Based on the evidence obtained during the investigation, licensee did not notify responsible party of change in condition as required by Title 22 regulations. (Continue on LIC9099C) (Continue from LIC9099C) The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the above allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D. A plan of corrections was developed with Administrator, Dacanay. An exit interview was conducted with Administrator, Dacanay and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit. (Continue from LIC9099A) R1 was bedbound and diagnosed with spasticity which caused R1 to have exaggerated deep reflexes and repetitive jerky motions especially when touched or moved. During interviews, staff stated that they did not know the source of the injury and denied any abuse. However, staff explained that due to R1’s medical condition, R1 would often become agitated and combative towards staff during incontinence care or repositioning. According to the care service plan, R1 required two-person assist and would often resist care by aggressively moving their arms and accidentally hitting staff or themselves during the process. Staff also indicated that the padding on R1’s bedrail had been removed by an outside source, which could have resulted in R1 accidentally hitting their face on the corner of the bedrail when switching sides. During a visit conducted on March 22, 2023, R1 was observed using the bed rail to pull themselves up to switch sides and the position of their face was in close proximity (approximately 2-inches) from the edge of the bed rail. During interviews, staff, residents, and outside sources indicated they had never witnessed any staff member mistreating or physically abusing R1 or any of residents. Based on the observations, review of records and interviews conducted with relevant witnesses, it appeared R1’s bruised eyelid may have resulted from R1 accidently hurting themselves with the bedrail. There was no evidence found of physical abuse by facility staff. CCL was not able to gather any corroborating evidence that supports this allegation. Therefore, this allegation is deemed to be unsubstantiated, as there is not a preponderance of evidence to prove the alleged violation occurred. An exit interview was conducted with Administrator, Dacanay and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.