Inspector’s narrative
What the inspector wrote
Review of Resident 1’s (R1) medical assessment records dated May 2021, revealed that R1 had a diagnosis of dementia, was confused and disoriented, was non-ambulatory, used a wheelchair, had bladder incontinence, had limited ability to communicate needs, and was unable to follow directions. R1 also required staff assistance with medication administration, bathing, dressing, grooming, feeding, transferring, and toileting care and had a physician prescribed diet. The Department attempted to interview R1 but the interview did not reveal any relevant information due to R1’s cognitive impairment and non-verbal state.
Interviews with staff and review of R1’s needs and service plan dated 2021 revealed that R1 required multiple staff to lift, transfer, and shower. Staff disclosed during interviews that staff were unable to request assistance from other staff while caring for any residents who required more than one person due to staffing level. Staff interviews revealed that some staff would refuse to shower R1 due to not having enough staff to lift R1. Interviews revealed that staff had falsified shower logs to falsely indicate that they had showered residents. Outside source interviews revealed that on multiple occasions, R1 was observed in soiled clothing or in the same clothing over several days. Interviews with outside sources revealed that R1 was observed to be wearing soiled briefs and clothing on multiple occasions.
Interviews with staff and outside sources and review of R1’s updated medical assessment and hospital discharge paperwork dated January 2023 revealed that R1 required staff assistance with oxygen administration through the use of a nasal cannula after being discharged from the hospital at the end of January 2023. Staff interviews revealed that R1 would occasionally pull the nasal cannula down and interviews with staff and outside sources revealed that R1 had been observed with the nasal cannula pulled away from their nose on several occasions. Review of R1’s needs and service plan dated 2021 revealed that staff were instructed to check on R1 “frequently” during the day and night, but the document did not specify a time period between checks or the number of checks to be conducted during a 24-hour day. Interviews with outside sources revealed that on more than one occasion, outside sources were unable to locate staff to provide direct care to residents. Outside source interviews alleged that staff were not available to assist residents, including R1, or did not respond to calls for resident care assistance for more than 30 minutes.
Continued on LIC9099-C page…
Onsite visits to the facility by the Department in January, February, and May of 2023 revealed that the facility lobby and resident rooms smelled of urine. During an onsite visit in February 2023, resident rooms were observed by the Department to be messy with clothing cluttered around the room, trashcans that contained soiled incontinence briefs, and bags of laundry piled outside of resident rooms. Evidence obtained during outside source interviews supported the allegation that R1’s room was observed to be cluttered and smelled of urine or other foul odors and that the facility smelled of urine and was not kept clean. Interviews with facility management stated that housekeeping staff were supposed to clean resident rooms two to three times a week and caregivers were responsible for disposing of soiled briefs daily. However, interviews with staff disclosed difficulties with meeting the care needs for residents and completing additional tasks such as laundry and housekeeping during their shifts due to workload and number of residents requiring care.
Review of the staff schedule for December 2022 revealed that approximately 4 staff were scheduled per 8-hour shift, with each staff member responsible for a different section of the facility or assigned as the medication technician for the entire facility. Interviews with facility management and staff stated that caregivers were responsible for collecting, washing, and returning residents’ clothing on a rotating schedule in addition to assisting residents with care needs. During interviews, staff voiced concerns that they were unable to meet the needs of residents due to the workload, staffing level, facility layout, and the number of residents needing care at the same time. Staff stated that during meals, kitchen staff were asked to supervise residents in the dining room while caregivers assisted residents with meals in their rooms. Interviews revealed caregivers were not able to assist all of the residents who required assistance with feeding due to workload. Interviews raised concerns that staff were unable to assist all residents who required feeding assistance and that those residents would be unable to eat food without assistance. Additionally, interviews with staff brought up concerns that staff could not track residents’ meal intake or determine if residents were finishing meals or losing weight. Interviews with staff revealed that R1 required assistance with eating meals and would eat all meals in R1’s room.
Continued on LIC9099-C page…
Evidence collected during staff interviews revealed that staff believed that R1 had not been assisted with meals and that meals were only being delivered to R1’s room. Staff voiced concerns that R1 had lost weight but there were no reports that R1 was finishing smaller portions of food or refusing meals. Hospital records show that R1 was diagnosed with acute hypoxic respiratory failure and aspiration pneumonia with sepsis while at the hospital in January 2023.
The Department has investigated the above-mentioned allegations and based on interviews, records reviewed, and Department observations, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D pages.
A civil penalty in the amount of $500 is being assessed per Health and Safety Code 1569.49(c)(1), for a violation that the Department determined resulted in the hospitalization of R1. The Wellness Director was informed that determination of civil penalties under Health and Safety Code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division.
An exit interview was conducted with
Wellness Director Rosa Barajas
, whose signature below confirms receipt of a copy of this report, and LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).
R1’s care was overseen by a non-profit agency who provided R1 with a physician and arranged R1’s medical appointments and transportation for medical care.
Interviews revealed that on 1/9/2023, Staff 1 (S1) contacted the Wellness Director after S1 observed that R1 had a change of condition that resulted in R1 having difficulty eating. After being notified by S1, the Wellness Director contacted the non-profit agency to have R1 seen by their physician. R1 was seen by the physician the same day who sent R1 to the hospital where R1 was diagnosed with acute hypoxic respiratory failure, aspiration, sepsis, and pneumonia. R1 remained in the hospital for 10 days and was discharged back to the facility on 1/19/2023.
When asked why R1 was not transported to the hospital from the facility when staff observed R1’s change in condition on 1/9/2023, the Wellness Director stated that the non-profit organization physicians were responsible for assessing and determining the necessary care for R1. Interviews confirmed that the Wellness Director, S1, or any other facility staff did not call 911 or emergency services for R1 on 1/9/2023. Once R1’s change in condition was observed, the Wellness Director arranged for R1 to be assessed by their physician on the same day. Interviews with facility staff revealed that staff are instructed to conduct status checks on residents every two hours which included assisting residents with meals and turning any bedridden residents like R1. During interviews, staff voiced concerns that they were unable to meet the needs of residents due to the workload, staffing level, facility layout, and number of residents needing care at the same time. Despite not calling emergency services for R1 once the change in condition was observed, the facility ensured that R1 was seen by medical providers and received medical care for the change in condition on the same day it was noted.
The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.
An exit interview was conducted with Wellness Director Rosa Barajas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
