Incident investigation·January 19, 2024

Licensing Program Analyst (LPA) Maja Jensen arrived on 1/19/24 for an unannounced case management to follow up on an incident report made by the facility. LPA Jensen met with Tha Chay and explained the purpose of today’s visit. Per facility’s Unusual Incident/Injury Report, on 04/20/2020, at approximately 7:30 am, facility staff answered Resident 1’s (R1’s) call. R1 reported she fell and hit her head. 911 was called. The Department conducted an investigation which consisted of a review of medical records and facility records. Records indicate that R1 was admitted to the facility on March 6, 2020. Facility notes document the following occurrences: -R1 had an appointment scheduled to remove a stent but this was postponed until May of 2020. -On 3/11/2020, R1 complained of pain in her back and no medical attention was sought. -On 3/14/2020, R1 complained of stomach pain and no medical attention was sought. -On 4/3/2020, R1 complained of stomach pain and no medical attention was sought. -On 4/4/2020, R1’s daughter was called. R1’s daughter stated she was aware of the stomach pains due to kidney stones. Staff suggested to increase fluids. -On 4/15/2020, R1 complained of stomach pain and no medical attention was sought. -On 4/16/2020 at 12pm and 6pm R1 complained of stomach pain and no medical attention was sought. -On 4/18/2020 Staff called daughter of R1 and informed her of the constant stomach pain. R1’s daughter stated she will try to schedule an appointment for Monday (4/20/2020). -On 4/20/20 R1 was admitted to the hospital with an admission diagnosis of severe sepsis, acute kidney injury, metabolic acidosis, hyponatremia and candidiasis. Continued on LIC 809C.... On 04/22/2020 10:30 pm R1 was pronounced dead at the hospital. The death certificate listed multi organ failure, septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst as immediate causes of death with congestive heart failure and atrial fibrillation as other significant conditions contributing to death but not resulting in the underlying cause of death. Based on the review of the medical records, and other miscellaneous documents, the facility delayed medical assistance and that resulted in a hospitalization leading to death from septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst. In addition, the facility did not recognize R1’s change in condition. Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. The Department is also reviewing additional civil penalties which may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted. A copy of this report, appeal rights and a confidential names list (LIC 811) was given to Tha Chay.