complaint·March 30, 2022

(Pg2) The Administrator was notified that the complaint was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Jose Santana. The LPA determined further investigation was required. On 09/07/2021, Investigator Santana conducted interviews with the reporting party, R1’s representative and Santa Barbara Long Term Ombudsman Program (LTCOP); on 10/05/2021, with facility staff; on 10/06/2021, with facility staff, Central Coast Home Health and Hospice, and attempted an interview with R1 (R1 was not able to be interviewed due to R1 could not provide the correct answers to the 10 Step Investigative Interview Protocol); on 11/03/2021, with R1’s former Primary Care Physician; on 11/05/2021, with Witness #1 (W1); on 11/19/2021, with Witness #2 (W2) and Central Coast Home Health Physical Therapist; and on 11/18/2021 and 11/24/2021, attempted interview/left message with R1’s Primary Care Physician. Investigator Santana reviewed copies of facility records and medical records related to R1. The information indicated R1, with a history of ataxia (impaired balance or coordination), Alzheimer’s dementia, and a fall risk, was admitted to the facility on 07/27/2021. R1 required a “Level 2” care program in memory care, based on a comprehensive assessment. The highest level in memory care is a Level 3. The physician report, dated 06/16/2021, listed the primary diagnosis as spinocerebellar ataxia for which R1 required a walker. Care and supervision needed for this condition was for R1 to receive medication and to be watched for falls. R1 was listed as having dementia and as being confused and verbally aggressive. R1 had the capacity to take care of toileting needs but required supervision with bathing and grooming. R1 had motor impairment that manifested as walking with a tremor, but could transfer independently to and from bed. Additionally, the Investigator reviewed R1’s preplacement appraisal, service plans, narrative charting, residency agreement, unusual incident report for the 08/08/2021 fall, internal incident reports, shift reports, physician communications, staff schedule and assignments, Emergency Medical Services (EMS) records, 911 call recordings, Santa Barbara Cottage Hospital records, Goleta Valley Cottage Hospital records, and Central Coast Home Health records. On 09/07/2021, Investigator Santana contacted the Santa Barbara Long Term Care Ombudsman Program (LTCOP) and was informed they would not be investigating the present allegation due to consent had not been received from R1’s representative. On 09/10/2021, the investigator contacted the Santa Barbara County Sheriff’s Office, Criminal Records, to inquire if there was a crime report for the present allegation. There was no crime report related to R1. (Continued on 9099-C) (Pg3) It was reported that R1 was brought into the Emergency Department at Goleta Valley Cottage Hospital on three (3) separate occasions. The first visit was on 08/07/2021, after R1 was found on the floor at the facility. R1 sustained a small hematoma to the left frontal lobe and was discharged back to the facility. The second visit occurred on 08/08/2021, after R1 was found on the bathroom floor. R1 suffered a laceration to right parietal region with controlled bleeding and a skull fracture and was transferred to Santa Barbara Cottage Hospital because of a subdural hematoma. The third visit occurred on 08/16/2021, after another unwitnessed ground level fall. A CT scan of the brain found a right anterior and posterior scalp contusion and hematomas. Based on the facility interviews, it appears the first fall, on 08/07/2021, occurred minutes after a caregiver had checked on R1 and that the fall perhaps could not have been foreseen because R1 had not previously fallen at the facility. However, a review of facility records revealed that the facility failed to follow its standard protocol in response to this first fall. The 48-hour monitoring and narrative charting did not take place for the entire designated time period, and there was no reassessment done despite R1’s continued agitation and attempts to leave the facility following the return from the hospital. While a MedTech contacted R1’s physician to report this agitation, there is no additional documented response to address R1’s behavior prior to the subsequent fall on 08/08/2021. The facility did not adequately address R1’s agitation and exit-seeking behaviors, which posed a risk to R1’s safety. R1 was only provided a one-on-one caregiver after the third hospitalization on 08/16/2021. Furthermore, no bed alarm was procured until the hospital insisted that one be provided after R1’s second fall. The allegation that R1 sustained head injuries requiring hospitalization from multiple falls, as a result of the facility’s Neglect/Lack of Supervision, is therefore Substantiated at this time. A $500 immediate civil penalty is assessed today. The Business Manager 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 deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.