Follow-up·November 7, 2024

On 11/7/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of closing an investigation conducted by the Department in regard to a self reported unusual incident report dated 4/21/2024. The incident report indicates that on 4/18/2024, staff checked on resident (R1) in their apartment, finding R1 laying on the floor with a plastic bag over (their) head, tied around (their) neck. Staff determined the resident was unresponsive. According to incident report, the hospice agency was called and then hospice instructed to call 911 due to the “unnatural death.” The Department has reviewed and gathered relevant records including facility incident reports, resident R1 needs & service plans, physician’s reports, daily chart notes and medical records related to this incident and determined the following: On 3/28/2024, R1 had indicated to their family and the facility a refusal to eat and additionally made statements of ending R1’s own life. R1’s family and the facility contacted 911 with R1 sent out for medical attention due to physical pain and suicidal statements. An updated care assessment for R1 had been completed on 3/25/2024 prior to this incident. No further care assessments were conducted after 3/28/2024 when R1 was sent out for medical assessment, or after 3/29/2024 upon R1’s return to the facility. There are no indications of increased status checks or assigning one-on-one care for R1 for preventative measures documented. Based upon the Department’s conducted interview and information gathered with the Health Service Director (S1) the following is indicated: S1 is a Licensed Vocational Nurse (LVN) at Ivy Park. S1 duties are to oversee the care staff, conduct assessments for new and existing residents, review resident’s medication, administer medication to residents, deal with family and resident concerns, and train care staff and medical techs. S1 continues, residents are checked on every one to two hours unless the service plans states that there should be more checks. Staff will not check on a resident if the resident does not want to be checked on. Residents are given an alert pendent when they first arrive at the facility. Continued onto LIC809-C The pendent allows the resident to call for help when they need it. There are no logs kept when a resident is checked on. When a new resident is admitted to the facility, S1 will conduct an assessment on the resident before they move in. The assessment is done to see what assistance the resident may need with their Activities of Daily Living (ADL) and their mental health status. S1 updates the service plans when a resident has a change in condition. The Department interview with S1 continued regarding R1 level of care and supervision and observations leading to R1’s death. This revealed that S1 was aware of the repeated suicidal statements made by R1 to staff and the hospice nurse. Although S1 admitted they were aware of the change of condition, S1 failed to complete a reappraisal for change in resident’s status and the need for increase status checks of R1 after repeated suicidal statements. S1 additionally indicated that residents are to receive one-on-one after indicating suicidal ideations. S1 however failed to ensure one-on-one care was provided for R1. Lastly, S1 admitted that they should have been more “on top of” R1s situation, provided more frequent checks, and provided R1 additional resources. Based upon the Department’s conducted interview and information gathered with the Executive Director (S2) the following is indicated: S2’s duties are to oversee the facility, manage the lead staff, work on the facilities’ financial, sign off on payroll for the facility, work with the facility nursing director, and approve and review incident reports. S2 continues, residents are checked on one time per shift. Caregivers can check on residents anytime during their shift as long as the resident is checked on before the end of the shift. Residents can refuse to be checked on. Residents are also given an alert pendant that they can press if they need assistance at any point in time when they have an emergency. No log is kept when a resident is checked on. When the facility accepts a new resident, an assessment completed by Health Service Director (S1) to determine the resident needs before they move into the facility. S1 also conducts a mental health evaluation to see if the resident requires memory care. The assessment is also performed to see if the resident is a fit for assisted living or memory care. S1 then reports to the care team what the new resident’s needs and level of care. After the initial assessment is performed, a second assessment is completed two weeks later to see how the resident is adjusting to the facility and determine any updated needs. A reassessment is performed every six months or when a resident has a change of condition. The facility considers a change of condition when there is a change in the resident’s baseline behavior or mental health status. Continued onto LIC899-C The Department interview with S2 continued regarding R1 level of care and supervision and observations leading to R1’s death . S2 indicated that when a resident states that they are going to harm themselves, Health Service Director, S1 is notified, S1 speaks with the resident, and notifies the resident’s Primary Care Provider and responsible party. S1 is to remove a ny harmful objects from the resident’s apartment if necessary and update the resident’s service plan to more frequent status checks every two hours. S1 is also responsible for making a recommendation to the family for the resident to receive one-on-one care paid for by the family. The facility can provide the one-on-one care to the family at an additional cost or with the option to pay for an outside company to and provide the additional care. If a resident has suicidal thoughts or attempts, they will be placed on increased status checks and will be checked on every two hours. The facility staff will also encourage the resident to socialize in the community more with the other residents. S2 was not aware of R1 having any mental health concerns when R1 arrived at Ivy Park. However, S2 was aware that R1 was exhibiting suicidal ideations with R1’s family calling 911 in March 2024 due to R1 stating that they were going to stop eating and made statement of wanting to commit suicide. The facility responded by sending R1 to the hospital for an evaluation. S2 stated that they required S1 to update R1’s needs and services plan upon return. Additionally, S2 addressed to S1 and R1’s family that R1 needed to be placed on hospice. S2 stated that R1’s care plan was updated to have assistance with his ADL’s but was not certain if S1 updated R1’s plan to have increased checks. Based upon document review it was found that R1 had bend sent out to the hospital for evaluation on 3/28/2024 and returned 3/29/2024. Record review found that the most updated needs and service plan was dated 3/25/2024 and input on 3/27/2024, prior to R1 initially being sent out for hospital. Interview continues indicating S2 was first aware of R1’s suicidal statement in March 2024. R1 was provided room checks every two hours before R1 made suicidal statements. Room checks were not updated and with R1 still provided room checks every two hours after R1 made his suicidal statements. S2 discussed one-on-one care with R1’s family but R1 never received the one-on-one care. On 04/18/2024, S2 indicated that Health Service Director (S1) and hospice nurse discussed R1 again stating that they wanted to commit suicide. The hospice nurse removed a pair of scissors from R1’s room and S2 held a follow up discussion with S1 regarding the one-on-one care for R1. S1 addressed to S2 that they did not follow back up with the family regarding the one-on-one care. On the same date 4/18/2024, R1 was found in their bedroom deceased. Continued onto LIC809-C S2 stated that after R1 made initial statements about taking their own life, the facility should have updated R1’s needs and services plan to include increased checks. S2 was not aware of why the increased checks were not implemented. S2 admitted that R1’s death could have been prevented if R1 was given one-on-one care sooner and was provided more supervision. The Department additionally conducted interviews with several caregiving staff but found information and statements to be inconsistent with investigation. An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. Additional Civil Penalty pending review per H&S Code Section 1569.49. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.