complaint·June 14, 2021

An outside source revealed, out of concern of the care provided by the facility, R1’s Responsible Party (RP) hired a 24-hour Private Caregiver (PC), later the PC's hours were reduced to 16 hours due to financial constraints, and was only able to provide one-on-one care during the morning to early evening hours. Interviews with facility staff revealed on January 16, 2020 between 19:00 and 20:00 hours R1 was watching TV in the common area of the memory care unit. There were two caregivers (S1 and S2) present to provide supervision, S2 had to repeatedly tell R1 to remain in the wheelchair after R1 had made several attempts to get up. S1 and S2 heard another resident yelling from their room. Both S1 and S2 left the common area to assist the yelling resident, leaving R1 unsupervised. When S2 returned R1 laying on the floor awake and alert, S1 and S2 assisted R1 back into their wheelchair and they all went to their room. During the initial interview S1 claimed to be present in dining room but did not witness the fall, however during a follow up interview, it was revealed S1 was not present and expressed being apologetic and acknowledged one of the two caregivers should have remained in the common area to supervise R1. R1’s responsible party and Seaport Hospice were notified of the fall, and R1 was evaluated by the Hospice nurse who did not recommend sending R1 to the hospital, and proceeded to monitor R1 from January 17,2020 to January 20, 2020 while R1 remained in and out of consciousness. A review of medical records revealed that after the fall R1 experienced a significant change in condition and remained unresponsive to external stimuli for several days appearing to be transitioning. Based on interviews and facility, resident, and medical record reviews the above allegation is determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. At this time, per Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with ED Amour. A copy of this report and Licensee/Appeals Rights (9058 01/16) was emailed to ED Amour at the conclusion of the visit, LPA Correia requested an electronic message reply to confirm receipt of these documents. An interview with the Resident Services Coordinator (RSC) revealed the facility caregivers continued to provide normal services in addition the Home Health agency and a private caregiver. A review of R1’s facility and medical records revealed logs of bathing and toileting/incontinence care on a consistent basis while at the facility. It was also alleged R1 was kept in isolation. Staff interviews revealed R1 would participate in facility activities on occasion, and after dinner would remain in the common area and watch TV with the other Residents. Interviews with outside sources and record reviews revealed R1 had consistent care from multiple agencies the entire length of stay at the facility, as well as visitations. It was alleged facility staff did not properly manage R1’s medication. Medical records revealed during R1’s medication management was overseen by outside sources for the entire duration of R1’s stay at the facility. A medical record review that on February 2, 2020 R1’s physician discontinued all prescriptions except for comfort medication. An Interview with the Reporting Party alleged R1 was given a discontinued medication due to not facility staff using an old version of the physician’s medication order. A review of the facility records and outside records did not indicate any medication errors. Interviews with the facility med tech was unaware of any medication errors. LPA was unsuccessful interviewing outside sources regarding the allegation. Due to lack of corroborating evidence, the finding regarding the above allegations 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 ED Armour and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was emailed to ED Armour at the end of the visit. An electronic email read receipt confirms the documents were received.