Inspector’s narrative
What the inspector wrote
[CONTINUED FROM LIC 9099]
Facility records and staff interviews showed R1 moved into the facility on 02-09-2020. According to their LIC602 Physician’s Report, LIC603 Resident Appraisal, and electronic charting from their home health agency, R1 was wheelchair-dependent but had no documented wounds, pressure injuries, or skin problems anywhere on their body at time of move-in. However, according to their LIC624 Needs and Services Plan and interview of licensee, R1 had existing “pressure ulcer on left & right heel.” Interviews and records showed R1 was incontinent and needed help with toileting. Starting in March 2020, R1 retained hospice care services due to increased weakness, confusion, and weight loss. In their separate interviews, the licensee and all four of the facility caregivers [i.e. S1, Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4)] each confirmed knowing that when R1 was in bed, R1 needed to be rotated/repositioned every two hours, around the clock, to prevent their skin from breaking down. R1 also needed to have their incontinence briefs checked at those times and changed if wet/soiled. These were also the instructions of R1’s hospice agency.
In their interviews, the licensee and all four caregivers also revealed that S1, S2, and S3 often worked consecutive (i.e. back-to-back) 24-hour shifts, meaning they slept over at the facility for multiple days at a time. S1 said they sometimes worked 3 to 4 days in a row. S2 said they sometimes worked 4 days in a row. S3 said they sometimes worked 5 days in a row. The facility’s work schedule reinforced these statements and additionally showed on some occasions during the complaint timeframe S1 and S3 worked 6 consecutive days, and on one occasion S2 worked 7 consecutive days. S4 sometimes worked 5 hours in the mornings as a housekeeper/second caregiver, and sometimes 1.5 hours in the evening to help put residents to bed. For 17.5 hours per day, however, S1, S2, and S3 were the sole caregiver for five residents in care. S1, S2, and S3 said during the overnight shifts they worked, they were the sole staff present and were expected to wake themselves up every two hours to go reposition R1 in bed and toilet them if needed. S1 said they would set an alarm for themselves “in case [they] fell asleep,” but that it was “exhausting.” S2 said R1 was “total care” and the facility was unable to meet their needs. S2 and S3 said they felt overworked and asked licensee to hire an overnight shift caregiver but were told the facility budget did not allow it.
[CONTINUED ON LIC 9099, 2 of 3]
[CONTINUED FROM LIC 9099-C, 1 of 3]
S1 claimed to have assisted R1 throughout the nights they worked. However, S3 said R1 developed a new pressure injury over a stretch of consecutive days when S1 worked. When S3 asked S1 if they had been assisting R1 every two hours, S1 replied they were “trying, but it’s hard.” After the next stretch of days S1 worked, S3 returned to the facility to find R1’s heel in even worse condition, indicating to them that S1 was not waking up to provide care. S4 said sometimes after they finished an evening shift, they returned to work the next morning to find R1 in the exact same position in bed that S4 left them in from the prior evening. On multiple mornings, S4 found soiled residents upon arrival to work, showered them, and applied ointment to their diaper rashes, but the rashes would come back. S4 said Resident #2 (R2) told them they were not toileted overnight. R2’s LIC603A Resident Appraisal showed they needed help with toileting. S2 said they once witnessed S1 wipe/clean R1’s private areas, but S1 was not thorough and “barely touched” them with toilet paper. S2 also observed that R1 and R2 both had diaper rashes.
Regarding R1’s bottom: On 03-19-2020, a facility caregiver wrote in the facility’s care log, “[R1] has a red spot on [their] right buttock that needs [to be] monitored.” Then on 04-30-2020, S3 wrote in the same log, “[R1] has 2 new wounds on bottom/coccyx area – [licensee] and hospice notified,” and S4 wrote, “[R1] had a bed bath washed, changed…has a stage 2 bed sore.” Later that day, a hospice nurse who visited R1 at the facility documented in the hospice agency’s notes: “excoriation” on R1’s bottom, conferral with the licensee, and instruction to facility staff to clean the area with soap and water, to keep repositioning R1 “side to side,” and to keep changing their incontinence products. Regarding R1’s right heel, on 04-23-2020, S4 wrote in the facility’s care log, “[R1] has a gray and black sore on the heel of foot.” A hospice nurse who visited R1 that same day wrote in the hospice agency’s notes, “Noted darkened spots on prominences of feet… Encouraged [staff] to use soft feet covers or socks and avoid tight fitting shoes... Provide cushion to feet against hard surfaces. [S3] reported bleeding from right heel this morning. Noted purplish discoloration on the area with small opening (dry). Wound care provided...” Then on 04-29-2020, S3 wrote in the facility’s care log that R1’s heel had worsened, but they did not indicate if they reported to the licensee or hospice staff.
[CONTINUED ON LIC 9099-C, 3 of 3]
[CONTINUED FROM LIC 9099-C, 2 of 3]
According to hospice agency documentation, between 03-25-2020 and 04-16-2020, licensee stopped R1’s hospice staff from entering the facility to inspect/care for them due to licensee’s concern about the wider community spread of COVID-19. CCLD reviewed its electronic database of prior-reported COVID-19 cases within licensed facilities, finding no indication that a Meadow Creek Villa staff or resident was COVID-positive either before or during said date range. The barring of entry to hospice staff, who are essential visitors, was inconsistent with CDSS’ guidance in Provider Information Notice (PIN) 20-04-ASC (published 03-05-2020) and PIN 20-07-ASC (published 03-13-2020). As a result, R1 missed 7 pre-scheduled Certified Nursing Assistant/Hospice Aide visits and 3 pre-scheduled licensed nurse visits. Licensee’s independent decision to stop hospice staff from entering the facility deprived R1 of third-party medical care for a couple of weeks.
Based on records and interviews, there is a preponderance of evidence showing licensee neglect resulting in R1 developing either new or worsening pressure injuries while under facility care. There is also a preponderance of evidence showing resident(s) overnight toileting/incontinence needs were not met. The allegations are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).
The Department has determined a violation resulted in injuries to a resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421 IM. Per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division.
A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Karpal, to whom a copy of this report, the LIC 9099-D, the LIC 421IM, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
[CONTINUED FROM LIC 9099]
Regarding the first allegation, the Department encountered no evidence to corroborate that S1 ever dropped R1 down onto their bed. Licensee and pertinent care staff said they never saw or heard S1 handle any resident in a physically rough manner. There is nothing in R1’s home health, hospice, or facility care/progress notes describing either R1 being fearful of S1, or R1 having a bruise, skin tear, broken bone, contusion, pain, or other injury which could be reasonably linked to the alleged rough handling. [R1 passed away prior to the complaint being filed, so they could not to be interviewed. Per their official death certificate, they died from natural causes unrelated to any physical injury.]
Regarding the second allegation, the Department encountered no evidence to corroborate that S1 left residents hungry, or that they did not serve them an appropriate variety of food. Licensee said residents are provided with three meals and two snacks per day, with second servings if requested. This matched the facility’s printed sample food menus, which featured a daily breakfast, lunch, and dinner, with snacks at 3:00 PM and 7:00 PM. The sample menus also showed a rotation of food items, such that staff could go seven weeks before repeating a food lineup. Interview of direct care staff and residents generally revealed that residents were satisfied with quantity and variety of food served. There was nothing in the facility’s progress notes showing that a resident was ever left hungry. On the contrary, caregivers often celebrated in their daily notes when residents displayed a good appetite. CCLD also observed that the required quantities of perishable and non-perishable food were present at the facility.
Regarding the third allegation, the Department encountered no evidence to corroborate that S1 left residents thirsty. Licensee said residents are provided beverages such as juice, tea, coffee, or milk with every meal, and are served water as often as they ask for it. The notion that residents had enough to drink was widely corroborated in caregiver and resident interviews. There was nothing in the facility’s progress notes showing that a resident was ever left thirsty or dehydrated. The facility also stored five 2.5-gallon jugs of emergency water on-site.
Based on interviews and records, a preponderance of evidence does not exist to prove the above three allegations. They are therefore unsubstantiated. An exit interview was conducted with Karpal, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
