Incident investigation·November 26, 2024

Licensing Program Analyst, Albert Johnson arrived on 11/26/2024 for an unannounced case management to follow up on an incident report made by the facility. On January 19, 2024, the Department concluded an investigation related to a death report for resident 1 (R1). Per facility’s Unusual Incident/Injury Report, on April 20, 2020, at approximately 7:30 a.m., facility staff answered R1’s call. R1 reported they fell and hit their head. 911 was called. R1 was admitted to the hospital with an admission diagnosis of severe sepsis, acute kidney injury, metabolic acidosis, hyponatremia, and candidiasis. On April 22, 2020, at 10:30 p.m., 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. The licensee was cited for California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, section 87466 Observation of the Resident. On August 8, 2024, a follow up visit was conducted due to the facility not arranging medical services for R1 when they reported being in pain on six separate occasions. The licensee was cited for California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, section 87465(a)(1) Incidental Medical and Dental Care Observation. At the time of the case management visits on January 19, 2024, and on August 8, 2024, immediate civil penalties totaling $1000 were issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in death based on Health and Safety Code Section § 1569.49(e). This is evidenced by information gathered through medical records that the facility failed to properly assess the resident’s needs and develop a plan of care to meet their needs; the facility failed to get timely medical attention for resident despite their long-standing complaints of pain; resident’s medications were not all available until after 5 days post admission to facility; resident’s medications that were not provided were crucial for cardiac, pain control, and post-procedure antibiotic; facility failed to recognize resident's complaints, symptoms, and change in condition that resulted in death. Today, 11/26/2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $1000 was previously issued on January 19, 2024, the amount of the civil penalty issued today will be $14,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Tha Chi and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.