inspection·July 25, 2022

[CONTINUED FROM LIC 9099] The Department’s investigation established that R1 moved into the facility in September 2019, while also under the parallel care of a hospice agency (which means comfort-focused care reserved for persons near end of life). According to their updated LIC624 Physician’s Report dated August 2019, R1 weighed 89.5 pounds (down from 103 pounds just six months prior), was “bedridden,” and was diagnosed with end-stage Alzheimer’s Disease. According to hospice records: by October 2019, R1 slept more during the day, lost another 6.5 pounds over 3 months, and required the assistance of two caregivers (instead of one) to transfer to a wheelchair. By December 2019, R1 slept 18 to 20 hours per day, and spoke an average of six words per day. From December 2019 to February 2020, R1 lost another 8 pounds and now needed to be manually fed all food and drink. Regarding the allegation that facility staff did not help R1 drink water, CCLD encountered evidence to the contrary: In December 2019, facility staff conducted a reappraisal of R1’s care needs, citing R1’s “cognitive loss,” inability to communicate verbally, dependance on “full assistance” with eating, and staff needing to “assist [in the] dining room for meals.” This reappraisal generated an updated written plan of care, which explicitly stated R1 required “full feeding assistance.” Multiple interviews corroborated that staff routinely helped R1 transfer to a wheelchair, took them to the dining room for meals, and sat one-on-one with R1 while they ate/drank, physically assisting them in doing it and observing how much was consumed. One staff described pro-actively offering “snacks and water” in between meals to memory-impaired residents, specifically because of their communication challenges. Regarding the allegation that facility staff did not assist R1 with continence care, CCLD encountered evidence to the contrary: R1’s care assessment described them having “cognitive loss” and requiring help with continence care. R1’s written plan of care stated R1 was incontinent of both bowel and bladder, wore disposable briefs, and required “total assistance” with bathroom needs. Multiple staff interviews corroborated that R1 regularly received such help. According to independent hospice records, in October 2019, R1 was identified as having developed a Stage 2 pressure injury on their bottom. However, on February 25, 2020, a hospice nurse documented R1’s pressure injury had “healed.” [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] According to a reference guide tiled, “Bedsores (Pressure Ulcers),” published by the Mayo Clinic on April 29, 2022, risk factors for bedsores include “immobility,” “incontinence,” and “poor nutrition and hydration,” and “skin becomes more vulnerable with extended exposure to urine and stool.” That facility staff successfully closed R1’s pressure injury suggests they timely attended to R1’s continence care needs, despite R1’s ongoing weight loss. According to facility internal progress notes (which were corroborated by the hospice agency’s own documentation): Beginning March 5, 2020, R1 appeared weak, their breath was shallow, and they had difficulty opening their eyes. They ate “four bites” of dinner, which they pocketed in their cheek instead of swallowing. Staff alerted the hospice agency. R1 then developed a low-grade fever which broke later that night, after a facility nurse gave them a Tylenol suppository and applied a damp towel to their forehead. On March 6, 2020, R1 displayed facial grimacing, restless arms/legs, and shortness of breath. Consulting with hospice, facility staff gave R1 as-needed morphine, which was effective in helping them relax and breathe. Staff connected R1 to supplemental oxygen, which helped them sleep. R1’s physician wrote an order to discontinue all routine medications since R1 was no longer “eating or tolerating routine meds.” Facility PM shift staff wrote that they checked on R1 every 30 minutes, repositioning them in bed every 2 hours. Facility overnight staff wrote they checked on R1 every hour. R1 stopped responding to voice or touch. On March 7, 2022, hospice initiated “Crisis Care,” meaning their nurse stayed bedside with R1 around-the-clock. On March 8, 2022, R1’s fever returned, and R1 was transported to the nearest hospital emergency room (ER). According to ER records: R1 arrived “comatose but breathing” with a “weak gag reflex.” R1 received an intravenous (IV) infusion, since they could not drink. Even after being rehydrated and starting antibiotics, R1 experienced no change in alertness, passing away nine hours later. According to ER records, the “primary impression” of R1’s death was “septic shock,” with “secondary impressions” of “severe dehydration, hypernatremia, acute renal failure, myocardial infarction, and pneumonia involving right lung.” Upon learning of R1’s health trajectory since March 5, 2020, the treating ER physician concluded it was natural that R1 arrived dehydrated, and said neither facility nor hospice staff failed R1 in this respect. According to R1’s official death certificate (obtained from the County of San Diego), R1’s immediate cause of death was “cardiac arrest” due to “myocardial infarction” and “occult coronary artery disease.” It also said, “sepsis etiology [is] unclear,” and other contributors were “acute renal failure and hyponatremia.” Based on hospital records and physician testimony, R1 was indeed dehydrated upon arrival to the ER, but this was due to R1’s own inability to drink water starting March 5th, 2020, and not due to staff neglect. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] Based on interviews and records, a preponderance of evidence does not exist to prove licensee did not meet R1’s drinking and incontinence care needs. Also, there does not exist reliable evidence showing that R1 primarily died from pneumonia or dehydration. Although R1 was dehydrated on their date of death, there is no evidence suggesting that facility staff were culpable. Both allegations are therefore unsubstantiated. An exit interview was conducted with Pestano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.