complaint·December 22, 2022

On 08/03/2022, between 12:22pm and 3:30pm, LPA Chavez conducted an unannounced 24-hour complaint visit. The LPA met with Brenda Victoria, Administrator, and informed the reason for the visit. During the visit, the LPA interviewed the Administrator, reviewed records and obtained pertinent copies of facility records. LPA explained that further investigation was needed. The Administrator was notified that the case was referred to Community Care Licensing Investigation's Branch (IB) for further investigation. Investigator Munoz conducted interviews on 09/26/2022, at approximately 10:47am, with facility staff; on 09/27/2022, at approximately 9:32am, with C1’s primary medical doctor; on 10/18/2022, from approximately 9:45am to 12:45pm, with the Administrator and staff; on 11/10/2022, at approximately 2:50pm, with staff; on 11/14/2022, at approximately 9:00am, with staff; and on 11/15/2022, at approximately 9:45am, with C1’s resident representative. Additionally, the Investigator reviewed copies of Twin Cities Community Hospital medical records, Central Coast Hospice records and facility documents related to C1. The physician report dated 06/04/2021 lists C1’s diagnoses as Developmental Delay, Autism, and special diet pureed with thickened liquids. C1’s Individual Service Plan (ISP) dated 05/11/2022, also indicates C1 is dysphagic and requires a pureed, level II dysphagic diet. The investigation revealed that on 07/25/2022, Staff #1 (S1) took C1 to the fair. S1 allowed C1 to drink soda without Thick It powder and have a few bites of non-pureed hot dog. The soda and food were not thickened or pureed, as was prescribed by the doctor due to C1’s dysphagia. On 07/26/2022, at 11:38am, C1 began making gurgling sounds, vomited, and was sent to the Emergency Room. C1 was discharged the same day with a diagnosis of possible viral gastritis and prescribed nausea medication. Continued on 9099-C. On 07/27/2022, at 11:49am, C1 returned to the hospital for ongoing vomiting and difficulty breathing. C1 had low oxygen saturations and coarse breath sounds. C1’s x-ray showed slight haziness to the right upper lung. The doctors discussed the patient plan with C1’s resident representative who requested C1 be placed on comfort care. On 07/30/2022, C1 was discharged back to the facility on hospice care. C1’s discharge diagnoses included acute hypoxic respiratory failure, aspiration pneumonitis, seizure disorder, developmental delay and comfort care. C1 was placed on Central Coast Hospice care at the facility with the diagnosis of acute hypoxemic respiratory failure. On 07/31/2022, at 10:20pm, C1 stopped breathing and became unresponsive. Staff contacted the hospice nurse to report the death. Copies of C1’s service plan and facility demographic sheet stated C1 was a severe choking hazard and C1 is dysphagic which required C1 to be on a pureed diet. All staff interviewed had knowledge of C1’s pureed diet plan. However, multiple staff confirmed that C1 had a bite of a non-pureed hot dog and sips of soda while at the fair on 07/25/2022. The administrator stated that the staff also gave C1 a dime size pieces of funnel cake and did not bring C1’s Thick It powder to the fair. Based on the statements provided and documentation obtained, the Department has sufficient evidence to support the allegation Staff did not follow resident's special diet. Therefore, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report emailed to the executive director and administrator. On 08/03/2022, between 12:22pm and 3:30pm, LPA Chavez conducted an unannounced 24-hour complaint visit. The LPA met with Brenda Victoria, Administrator, and informed the reason for the visit. During the visit, the LPA interviewed the Administrator, reviewed records and obtained pertinent copies of facility records. LPA explained that further investigation was needed. The Administrator was notified that the case was referred to Community Care Licensing Investigation's Branch (IB) for further investigation. Investigator Munoz conducted interviews on 09/26/2022, at approximately 10:47am, with facility staff; on 09/27/2022, at approximately 9:32am, with C1’s primary medical doctor; on 10/18/2022, from approximately 9:45am to 12:45pm, with the Administrator and staff; on 11/10/2022, at approximately 2:50pm, with staff; on 11/14/2022, at approximately 9:00am, with staff; and on 11/15/2022, at approximately 9:45am, with C1’s resident representative. Additionally, the Investigator reviewed copies of Twin Cities Community Hospital medical records, Central Coast Hospice records and facility documents related to C1. The physician report dated 06/04/2021 lists C1’s diagnoses as Developmental Delay, Autism, and special diet pureed with thickened liquids. C1’s Individual Service Plan (ISP) dated 05/11/2022, also indicates C1 is dysphagic and requires a pureed, level II dysphagic diet. The investigation revealed that on 07/25/2022, Staff #1 (S1) took C1 to the fair. S1 allowed C1 to drink soda without Thick It powder and have a few bites of non-pureed hot dog. The soda and food were not thickened or pureed, as was prescribed by the doctor due to C1’s dysphagia. On 07/26/2022, at 11:38am, C1 began making gurgling sounds, vomited, and was sent to the Emergency Room. C1 was discharged the same day with a diagnosis of possible viral gastritis and prescribed nausea medication. Continued on 9099-C. On 07/27/2022, at 11:49am, C1 returned to the hospital for ongoing vomiting and difficulty breathing. C1 had low oxygen saturations and coarse breath sounds. C1’s x-ray showed slight haziness to the right upper lung. The doctors discussed the patient plan with C1’s resident representative who requested C1 be placed on comfort care. On 07/30/2022, C1 was discharged back to the facility on hospice care. C1’s discharge diagnoses included acute hypoxic respiratory failure, aspiration pneumonitis, seizure disorder, developmental delay and comfort care. C1 was placed on Central Coast Hospice care at the facility with the diagnosis of acute hypoxemic respiratory failure. On 07/31/2022, at 10:20pm, C1 stopped breathing and became unresponsive. Staff contacted the hospice nurse to report the death. C1’s death certificate listed the immediate cause of death as acute hypoxic respiratory failure with conditions leading to the cause of death as aspiration pneumonia and oropharyngeal dysphagia. The Twin Cities Community Hospital records noted C1 was initially seen for nausea and vomiting. C1 was discharged and later returned for continued vomiting and trouble breathing. C1 was diagnosed with acute hypoxic respiratory failure and aspiration pneumonitis, likely caused by ongoing vomit. C1’s primary medical doctor stated Thick It mix was prescribed to assist C1 with food texture due to swallowing difficulty and it was to be taken as directed. The doctor stated that there is a possibility that if staff gave C1 a drink without the Thick It, C1 could have developed a cough and it may have contributed, but he did not believe this would have been the cause of death. Based on the statements provided and documentation obtained, the Department does not have sufficient evidence to support the allegation Questionable Death. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report emailed to the executive director and administrator.