Inspector’s narrative
What the inspector wrote
Throughout R1 residing at the facility, interviews with staff and R1’s family revealed R1’s health declined from being ambulatory with the use of a walker, to eventually wheelchair bound.
Assessments conducted by the facility for R1 on 1/4/18, 2/6/18, 8/1/18, 1/31/19, 8/16/19, 2/15/20, and 6/24/20, consistently revealed R1 was at high risk for falls. Narrative charting records documented on June 3rd, 2018, R1 sustained a witnessed fall, R1 hit a wall, and staff summoned medical attention due to R1 sustaining a skin tear to the head. On January 31st, 2019, during the overnight shift, staff found R1 on the floor next to R1’s bed with a laceration to the head, and staff summoned medical attention. R1 was transported to the hospital on both occasions, with the fall on 1/31/2019 requiring stitches. Review of photographs obtained from R1’s medical provider, confirmed R1 suffered lacerations on both occasions.
From approximately March 24th, 2018, to October 11th, 2019, R1 sustained approximately twelve (12) witnessed and unwitnessed falls. On at least seven of the twelve noted falls, R1’s falls were unwitnessed. A Service Plan for R1 dated January 31st,2019, did not reveal any measures addressing R1's falls. On subsequent visits the Department requested records, but the facility was not able to produce such records, including service plans addressing R1’s falls.
Although staff reported checking in on R1 every two hours, the facility did not implement any fall prevention measures for R1 until after the fall on January 31st, 2019, which resulted in a hospital visit and R1 sustaining a laceration requiring stitches. By January 31st, 2019, review of records revealed R1 had sustained approximately ten (10) falls with no severe injuries. Interviews with multiple staff and R1’s family corroborated the facility implemented fall prevention measures after January 31st, 2019. The measures included placing bed rails and lowering of the bed. An Outside Agency Form dated January 31st, 2019, revealed fall prevention measures were discussed with staff on that date. The measures discussed with the external agency included lowering R1’s bed, conducting frequent checks and cleaning R1’s room to minimize trip hazards. During the investigation the facility produced assessments and service plans for R1, but these did not indicate what fall mitigating measures were implemented, nor what staff actions were implemented to mitigate R1’s falls.
(See additional LIC 9099C form for continuation of report.)
R1’s diagnoses included Hypernatremia (High Concentration of sodium in blood) due to Hypovolemia (decreased volume of circulating blood). There were no diagnoses related to, nor suspecting lack of fluid intake noted in the discharge summary. At the time of discharge form the hospital, R1’s diet had changed to nothing by mouth, until R1 was “more awake, and passes swallow eval”. The hospital's progress notes dated June 25th, 2020, noted R1 was hospitalized from June 22nd, 2020, to June 24th, 2020, with bilateral pneumonia and hypernatremia. Although Hypernatremia was noted as a admitting diagnoses, there were mentions of dehydration being a diagnosis. Additional interviews with multiple residents did not reveal there were concerns with lack of assistance with food, nor with lack of fluids available to residents.
It was alleged neglect resulted in pneumonia. A source reported R1 was hospitalized and diagnosed with Pneumonia. The reporting party questioned how R1 suddenly developed Pneumonia as it could not happen overnight. Records obtained from R1’s medical care providers, including a hospital discharge summary and progress notes dated June 25th, 2020, and a hospice agency revealed the Pneumonia was likely bacterial and the suspected cause was aspiration (inhalation of foreign object or substance into the airways). Interviews with staff revealed R1 was assisted and seated at 90 degrees, as there was concerns of aspiration due to R1’s difficulty swallowing. Interviews with staff also revealed R1 had developed a cough for approximately a week prior to being hospitalized on June 20th, 2020. Staff notified R1’s family and R1’s primary care physician. On June 205th,/20, emergency medical services were summoned as R1 presented low oxygen levels and was congestion.
It was alleged staff did not administer medication as prescribed. A source alleged the facility staff over medicated R1, as R1 seemed to sleep more and was less responsive. Interviews with residents, staff, resident’s responsible parties, and the Long-Term Care Ombudsman office did not reveal any concerns with staff over medicating residents. The LPA reviewed the Department’s Guardian system to locate the staff who was mentioned, but contact attempts were not successful. Additionally, the LPA requested additional records for review, but the facility was not able to produce such records.
Based on the investigation, there was not enough evidence to prove the alleged violations occurred, therefore, the allegations were Unsubstantiated.
An exit interview was conducted with Zepeda, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.
Based on evidence obtained, the allegation of staff neglect resulting in resident sustaining injury, was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D form.
An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Jessica Zepeda. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division.
An exit interview was conducted with Zepeda, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058), were provided.
