complaint·October 1, 2021

Medical assessment indicate that R1 is non-ambulatory and requires a 2-person assist with transfers. On October 20th, 2019, interviews and records revealed that R1’s private caregiver called the front desk around 2:45PM to request for assistance in R1’s room. Evidence obtained from staff interview confirms that the private caregiver reached out to the front desk to ask for assistance and advised that they will be leaving shortly. Front desk alerted facility staff that R1’s private caregiver is requesting for assistance. Around 3:00PM, another call was made to the front desk from the private caregiver to report that no staff have responded to the initial request. Another attempt was made by the Receptionist to alert staff that R1’s private caregiver is asking for assistance. Around 3:30PM, private caregiver came down to the front desk and notified Receptionist that they are off work and R1 is in her wheelchair. Private caregiver reported that none of the staff came in to check on R1 to provide them assistance. From on or about 2:45PM to 5:10PM, none of the facility staff checked in on R1 or responded to the multiple request made from the caregiver. Interview with Administrator revealed that staff do not typically check on residents with a private caregiver unless they request for assistance. Around 5:10PM, facility staff (S1 – See Confidential Names List on LIC 811) came in to check on R1 while making their rounds and was found on the floor in their room, next to their bed. An assessment was conducted on R1 and a bruise was observed on their right side of rib and lower leg, but no pain or fractures incurred from the fall. Based on evidence obtained from interviews and record reviews, it was determined that the facility staff neglected to respond to R1’s private caregiver’s request for assistance. Although staff acknowledged that R1 is a 2-person assist, no response was received when multiple attempts were made to request for help, leaving R1 on their own after the private caregiver left. Therefore, the allegation is found to be substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted with Executive Director, and was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents. It was alleged that R1 was left soiled for an extended period of time on October 20 th , 2021. Interviews conducted with staff revealed that R1 was found in the room with soiled diaper. Medical records revealed that R1 has a bowel and bladder incontinence and she is dependent in all Activities of Daily Living (ADL) including toileting and incontinence care. Evidence obtained from interviews revealed that staff makes their round every two hours to check in on residents. A private caregiver to supervise R1 from 10 :00 AM to 3:30PM and one of their duty is to provide incontinence care. On October 20 th , 2021, R1’s private caregiver left the facility around 3:30 PM. Around 5:10PM, facility staff checked on R1 and found them on the floor with soiled diapers. Interview with outside source did not express having observed R1 with soiled diapers. Although it was claimed that R1 was observed with soiled diaper on one occasion, interviews conducted with other relevant individuals revealed that bi-hourly checks are conducted which includes incontinence care and there are no other concerns expressed regarding incontinence care. It was alleged that facility failed to meet R1’s needs by not being provided adequate amount of liquids and food which led to weight loss. Interviews and records indicate that R1 required assistance with eating, and it was discovered that private caregiver and/or facility staff assists with their with meals by feeding. Evidence obtained from medical records revealed that R1 has a health condition that makes it difficult to swallow food or liquid. Furthermore, records show that R1 switched to pureed food and was provided Ensure when it became difficult to eat. The Department observed that R1 had water and Ensure kept in their refrigerator. Interviews conducted revealed that staff ensured R1 was provided water or other liquids such as Ensure. Interviews determined that during the day, private caregiver assisted with feeding R1; in the evening, it’s the facility staff. Interviews with staff reported that R1 did not have any issues with eating, and typically had an appetite. However, due to their health condition, their appetite have decreased which was indicative to their weight loss. Facility records documents when R1 was provided their meals whether its pureed, Ensure or chopped meals. It was alleged that facility failed to safeguard resident’s belongings such as a CD player and CD’s belonging to R1. A review of R1's record did not include an inventory list to indicate any of the missing valuables (LIC 621) that were reported. Furthermore, staff were unaware of the missing items and advised that these were not reported as theft and loss. An interview with relevant person’s denied seeing a CD player or CD’s in R1’s room. This relevant person also denied that R1 owned those items. Furthermore, staff and outside source reported that R1 does not listen to music in their room. There is no evidence to support the allegation that facility failed to properly safeguard R1's personal belongings. Based on interviews, observations and review of documentation, the findings were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Executive Director and was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.