Inspector’s narrative
What the inspector wrote
On June 16, 2020, the licensee conducted a reassessment of R1's level of care needs. The reassessment established that overnight supervision was also needed, as the licensee documented that R1 required overnight pain management and incontinent care due to their non-ambulatory status in transferring independently.
In reviewing the facility's license and their Plan of Operation, the facility is licensed for six (6) non-ambulatory elderly residents, at which four (4) out of the six (6) residents may be bedridden. Moreover, the Community Care Licensing Division's (CCLD) records also showed that the licensee has a hospice waiver approval to serve four (4) out of the six (6) residents. According to the facility's Plan of Operation under Care of bedridden Persons, its states, "Residents who are bedridden will received care and supervision appropriate to their needs. Residents will be evaluated for complications of immobility. A service plan will be developed that addresses the needs of the resident and evaluates quarterly. Staff scheduling will accommodate the resident's needs, requiring turning and repositioning to tenure turning is taking place at least every two hours or more often as required. One-on-one staffing will be provided if it is determined to be needed by the resident." In reviewing the facility's hospice plan, it states that the licensee will develop a plan that describes the licensee's responsibilities including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), at which the description shall include the type and frequency of the tasks to be performed by the facility.
On August 30, 2020, R1 was transported to the hospital due to an altered state of mind and discharged the next day with new medication orders. The review of the discharge records did not reveal R1 had any pressure injuries. On or about September 01, 2020, R1 was assisted to the living room to sit in a recliner by the facility staff. While R1 was sitting in the recliner talking to their responsible party, they pressed their call alert alarm for assistance. As staff did not respond, R1's responsible party called the licensee to inform them that R1 needed help off the recliner. Upon the licensee returned to the facility, they asked R1 if they were stuck in the recliner. R1 replied they were not stuck on the recliner but needed assistance. The licensee responded by stating, "If you are not happy here, you can leave, and go to another licensed facility." An interview with the licensee confirmed that the statement was said to R1 while they sat in the recliner.
On September 11, 2020, R1 was again transported to the hospital due to their increase in weakness. According to the hospital's records, the physician conducted a physical examination of R1's state and skin. The assessment revealed no abnormalities except that R1 was present with a fever, abdominal pain, and weakness. On September 16, 2020, R1 was discharged from the hospital and returned to the facility.
On September 18, 2020, R1 was again transported to the hospital due to chronic pain. While in the hospital, R1 was assessed, and the physical exam revealed no abnormalities except for mild distress due to pain. On September 22, 2020, R1 was reexamined, at which it was observed that R1 had ulcers on their lower back. R1 was discharged from the hospital with the recommendation of receiving hospice services.
On September 22, 2020, R1 was evaluated and admitted to hospice. According to the comprehensive assessment conducted by hospice, dated September 22, 2020, it showed that R1 had a change in condition, as the evaluation revealed that R1 required maximum assistance with all their activities of daily living, such as transferring, dressing, grooming, bathing, ambulation, and medication management. Furthermore, the hospice also documented that they observed three small blisters located in the sacrum and coccyx, at which hospice provided medication and repositioning training to the facility staff. On September 23, 2020, hospice documented R1 as bedbound, assessed R1's skin, and provided training to the facility staff. On September 25, 2020, hospice conducted a routine visit and observed R1's coccyx area to be pink. Hospice again provided the facility staff with training on meeting R1's care needs. On September 30, 2020, hospice made a follow-up visit and observed multiple small red areas around the coccyx region. Hospice again provided training and instructed the facility staff to reposition the resident every two hours.
On the same day, at approximately 09:50 AM, the licensee reported another change in condition and requested a modification to R1's medication. Hospice provided training in meeting R1's medication needs, at which the licensee refused and demanded hospice to meet all of R1's medication needs. As the agency medical professional attempted to provide consultation on the responsibilities of the hospice agency, the licensee ended the phone conversation by hanging up the phone on them. However, an interview with the hospice agency confirmed that the licensee did complied R1’s medication. On September 30, 2020, at about 07:44 PM, hospice called the facility to conduct a welfare check on R1. Hospice spoke with the licensee and inquired about R1's repositioning needs. The licensee replied, "Don't blame me or us for the skin breakdown; it's from the hospital."
As hospice staff again attempted to provide consultation to the licensee, the licensee ended the phone conversation once more by hanging up the phone on them. On October 01, 2020, hospice conducted another routine visit for wound management and found R1 to be in pain, agitated, and crying out, "help me." Hospice again provided facility staff with training in meeting R1's care needs. However, the records showed that the licensee was unwilling to accept hospice training in meeting R1's care needs. On October 03, 2020, hospice made another routine visit for wound management and observed R1 with an unstageable pressure injury located on their coccyx. Hospice again documented that they provided the facility staff with training. On October 04, 2020, hospice conducted another routine visit for wound management and observed a new skin tear located on the sacral area, at which hospice again provided repositioning training every two hours to facility staff. On October 08, 2020, R1 passed away with a cause of death documented as Chronic Obstructive Pulmonary Disease with the contributed factor recorded as Encephalopathy. Though staff interviews were inconsistent, hospice’s records and their interviews supported the allegations.
Based on the review of records and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is SUBSTANTIATED. California Code of Regulations (Title 22, Division 6), deficiencies are cited on the attached LIC 9099D.
An exit interview was conducted with Licensee Amelia Perlow, and their signature on this report was obtained. The Licensee/Appeal Rights (LIC 9058 01/16) and a copy of this report was emailed to them. A return email from the license will confirm receipt of documents.
