complaint·March 12, 2024

Interviews revealed that the caregivers are responsible for ensuring water is always available for the residents and encouraging them to drink water. Staff would give R1 their medication in the dining area during breakfast and lunch. R1 always requested a glass of water to take their medications. Interviews revealed several staff members would always make water available to R1 and encourage them to drink it during their visits. However, R1 did not like water and would often refuse. Interviews revealed a cup of water was kept on a night stand next to R1’s bed. R1 in addition to water was also provided Ensure protein drinks several times a day to supplement for their lack of fluid intake and juice during meals. Interviews revealed that R1 liked Ensure and they normally finished the drink when it was provided to them. After a review of Medical Records from Sharp Memorial from R1’s visit on 7/23/2020, there was no indication/mention of dehydration. Dehydration was first reflected in Scripps Green Hospital medical records after R1 was transferred on 7/24/2020. Interviews with outside sources stated they did not believe facility staff would be able to adequately evaluate a resident for dehydration due to their lack of training. The allegations of staff neglected resident resulting in a urinary tract infection and neglect/lack of care and supervision by facility staff resulting in dehydration is unsubstantiated. Based on the evidence obtained from interviews, and records review, the complaint allegations are unsubstantiated. An exit interview was conducted with Liz Najera, Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit. On August 6, 2020, R1 passed away due to Failure to thrive and Granulomatous disease. The death report also stated that other significant conditions contributing to the death were injuries sustained from a fall on July 23, 2020 and Cardiac Disease. Based on records and interviews conducted, R1’s fall may have been prevented if S1 was following facility policy/protocol when transferring R1; therefore, the allegation of neglect resulting in R1’s fall and subsequent death is substantiated. It was alleged that staff did not seek medical attention for resident in a timely manner. Interviews revealed R1’s neighbor (R2) was returning from dinner, and they walked to R1’s room to visit them. Upon arrival, R1’s door was open and R1 was lying in bed. Interviews revealed R2 observed R1 to have a distressed look on their face and they reached up toward R2 with their hand. Interviews revealed R1’s hand was very clammy. R1 expressed that they were in a lot of pain and R1 begged R2 to get them some help. Interviews revealed R2 immediately went to the nurse’s station and advised a nurse that R1 was in pain and needed to go to the hospital. Staff called for an ambulance and R1 was transported to the hospital. A review of records reviewed from the ambulance company show that they received the call from Cornado Retirement Village at 7:40 PM and immediately dispatched an ambulance to the facility. The ambulance arrived at the facility at 7:51 PM and transported R1 to the hospital. The ambulance arrived at the hospital at 8:33 PM. A review of the Ambulance Service Incident/Response report revealed that facility staff were unsure if R1 hit their head and that R1 was given Tylenol for pain, but they weren’t able to state the time that the medication was given. The report also revealed that staff advised Emergency Medical Technicians (EMT) that the resident was observed increasingly lethargic since their fall at 1:00 PM. The report also documented that staff described R1 as normally talkative and polite, but on this day R1 was refusing to let staff touch them. When EMTs assessed R1, R1 displayed 10/10 sharp pain in right hip and bilateral lower extremities that worsened significantly upon movement or palpitation and yelped in pain. EMTs asked R1 what happened but R1 couldn’t recall the fall. The report documents bilateral bruising on anterior aspect of R1’s shins. R1 also had a skin tear on the right knee, covered with a band aid. The facility’s Training/Policy states the following: … emergencies include, but are not limited to: Shortness of breath, bleeding, trauma, chest pain or other notable pain, fainting, fall, stroke, unconsciousness, suicide thoughts/action, severe dehydration/weakness, dizziness, delirium, aggressive behavior, or any life-threatening situations, Do Not delay in guessing or assuming; The Med-Tech on shift or attending staff must immediately call 911. Based on staff and resident interviews, a review of the Ambulance Service Incident/Response report, and review of the facility’s Training/Policy, the allegation of staff neglecting to immediately telephone 9-1-1 for an injury is substantiated. Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, and are noted on the attached LIC9099-D. An immediate civil penalty of $500 was assessed for the following violation: Incidental Medical and Dental Care. Incidental Medical Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health… At this time, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division Based on the evidence obtained from interviews, and records review, the complaint allegations are substantiated. An exit interview was conducted with Liz Najera, Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.