complaint·June 19, 2024

[Continued from LIC9099] On January 11, 2023 hospice medical records indicated Resident 1's (R1’s), (See LIC811 Confidential Names list) health was declining citing a significant weight loss of 13 pounds from R1's admission weight. R1 was refusing to take medications and food. R1 was also experiencing auditory and visual hallucinations. Despite antibiotic treatment, R1 had not improved. R1 was a documented fall risk due to being non ambulatory and requiring a wheelchair (Geri Chair). R1 had an order for a half rail, a fall matt next to the bed and R1 was provided with a pendant to call for assistance. R1's care records documented that R1 was checked every two hours in the room and brought out to the dining or activity room during the day to be better supervised by staff. Records revealed that R1 had no documented falls requiring medical treatment prior to January 18, 2023. There is no documentation in R1’s Physician Report or Service plan that indicated R1 was a two person assist. On January 18, 2023 according to staff interview, Staff 1 (S1) had changed R1 and was preparing to transfer R1 from the bed to the Geri Chair. S1 turned away from R1 momentarily to move R1’s Geri Chair closer to the bed. When S1 turned, R1 rolled out of bed to the floor. S1 immediately called for assistance and R1 was assessed by Staff 2 (S2) for injuries. Outside Source (OS1) was called to inform OS1 about the fall and OS1 instructed S2 to assist R1 from the floor and place R1 back in bed since there were no visible injuries or complaints of pain. Once R1 was back in bed, R1 exhibited signs of pain on the hip. S2 called back OS1 and S2 was instructed to give R1 pain medication. On January 19, 2023 OS1 visited R1 and observed R1 in pain and discussed care options with Outside Source 2 (OS2). The options were to send R1 to the hospital to be evaluated or to remain at the facility and provide pain medication to R1. Outside Source 2 (OS2) elected to have R1 remain at the facility and continue to provide pain medication. On January 23, 2023 OS2 decided to send R1 to the hospital due to pain that was not subsiding with pain medication. [Continued on LIC9099C] [Continued from LIC9099C] On January 23, 2023, the hospital diagnosed R1 with a pelvic fracture. Due to R1's age, respect for R1's Code status and declining health, R1 did not undergo surgery. OS1 stated that R1's dementia was worsening and R1's health was declining prior to R1's fall. R1’s Physician Orders of Life Sustaining Treatment ( POLST) indicated Do Not Resuscitate (DNR) with Comfort Measure Treatment. OS1 stated falls causing injury are common with dementia patients and it is difficult for them to recover. Hospice was immediately notified, and care options were discussed. R1 was eventually sent to the hospital on January 23, 2023 when the pain medication was not working. Based on the Department interviews, observations and records reviewed there is not a preponderance of evidence to support that neglect contributed to the death of R1, therefore the allegation is unsubstantiated. An exit interview was conducted with Sabrina Priesman Executive Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. The Licensee was provided a copy of their Appeal Rights (LIC 9058 03/22), and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided to Sabrina Priesman Executive Director . [Continued from LIC9099] On January 18, 2023 Resident 1 (R1), (Please refer to LIC811 for a list of confidential names list), had a witnessed fall.  Interviews with facility staff revealed that the Unusual Incident/Injury report was not completed because R1 initially did not have any visible injuries or any complains of pain.  Records reviewed and staff interviews revealed that when R1 was transferred from the floor to the bed, R1 expressed pain. The facility staff confirmed that the Unusual Incident/Injury report was not completed for the incident. On January 23, 2023 R1 was sent to the hospital via 911 and was diagnosed at the hospital with a fractured pelvis. The facility staff was asked if an Unusual Incident/Injury report was completed and the staff confirmed that there was no Unusual Incident/Injury report completed for the hospital transfer of R1. On January 31, 2023 R1 passed away and the facility staff was asked if an Unusual Incident/Injury report and a Death Report was completed.  The facility staff confirmed that there was not an Unusual Incident/Injury report completed for R1.  Outside Source 1 (OS1) and Outside Source 2 (OS2) requested a copy of the Unusual Incident/Injury report for R1's fall, the transfer to the hospital and the Death Report and the facility staff confirmed that the reports requested were not given due to the facility staff did not complete the reports. The facility staff also confirmed that Community Care Licensing Regional Office did not receive the Unusual Incident/Injury reports because no reports were completed. Based on interviews, observations and review of documentation including medical records, the above allegation is substantiated . This finding means that the preponderance of evidence has been met and the allegation is valid. The deficiencies are cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted and a plan of correction was established with Sabrina Priesman Executive Director. A copy of this report along with licensee Appeal Rights (LIC 9098 03/22) was given to Sabrina Priesman Executive Director whose signature below confirms receipt of these rights.