Incident investigation·August 8, 2024

Licensing Program Analyst (LPA) Maja Jensen arrived on 8/8/24 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. Between the dates of 3/11/2020 and 4/16/2020, facility notes document that R1 complained of pain 6 times on 5 different dates and facility did not seek medical attention for any of these 6 incidents. On 4/20/24 R1 was sent to the hospital due to a fall during which she hit her head, she was admitted to the hospital and diagnosed with severe sepsis, acute kidney injury, metabolic acidosis, hyponatremia and candidiasis. On 04/22/2020 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 investigation shows that despite R1’s repeated complaints of pain, the facility did not contact R1’s physician or seek medical treatment which lead to death from septic shock, septicemia with Escherichia coli, and an infected urinary cyst. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.