Complaint·June 11, 2024

During the visit, the LPA conducted a physical tour of the facility and requested and obtained documents pertinent to the investigation. The Administrator at the time was notified that the complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jose Santana for further investigation. Investigator Santana conducted interviews on 07/06/2022, at approximately 4:00pm, with R1’s resident representative; on 07/12/2022, from approximately 1:05pm to 3:30pm, with facility staff; on 07/13/2022, from approximately 7:00am to 3:30pm, with facility staff, Memory Care Director and former facility Executive Director; on 07/18/2022, at approximately 11:00am, with Memory Care Director; on 08/02/2022, at approximately 5:05pm, with Cottage Hospital attending physician; on 08/05/2022, at approximately 6:50pm, with Cottage Hospital attending physician; on 08/09/2022, at approximately 3:40pm, with R1’s resident representative; on 08/23/2022, at approximately 10:25am, with Central Coast Home Health Services (CCHS) and on 08/24/2002, at approximately 10:30am, attempted interview with R1’s Primary Care Physician (PCP). Additionally, Investigator Santana obtained and reviewed copies of R1’s facility file documents, hospital records and home health records. On 12/24/2020, at 3:46pm, R1 arrived at Santa Barbara Cottage Hospital (SBCH) via ambulance for a sudden onset of difficulty in breathing, according to the Skilled Nursing Facility where R1 was residing. While at the hospital, R1 was diagnosed with COVID-19, anasarca, hypoalbuminemia, hypokalemia, among other conditions. R1’s sepsis screen showed a suspected infection, and a urinalysis showed an abnormal result. R1 had also previously had sepsis on 09/17/2020. R1 had a history of diabetes mellitus, high cholesterol, and hypertension, along with atrial fibrillation, gastritis, hiatal hernia with GERD, cholelithiasis, Schatzki’s ring, and prior alcohol abuse with liver disease. Continued on 9099-C On 01/01/2021, SBCH attempted to locate skilled nursing facilities that would accept R1. The hospital records also noted physical therapy was attempted with R1, but R1 declined to participate, saying they were “too tired”. On 01/04/2021, R1 was diagnosed by the hospital registered dietician (RD) who noted R1’s malnutrition was likely related to multiple chronic medical issues as evidenced by weakness, prior weight loss, and ongoing inadequate oral intake; R1’s nutrition risk level was moderate. R1’s blood glucose was being controlled with R1’s current insulin regimen and carb-controlled diet. The RD suspected R1’s appetite would improve as acute issues improved and R1 was in a more comfortable environment. On 01/05/2021, the attending physician noted that R1’s prognosis had been full recovery back to baseline of underlying dementia. On 01/06/2021, the case manager informed R1’s resident representative that no skilled nursing facilities were accepting residents in the area. R1’s resident representative advised that they were considering placement at the Pacifica Senior Living facility. The facility administrator agreed to admit R1 the following day on 01/07/2021. R1 was discharged from the hospital on 01/07/2021 at 3:41pm. A review of the Physician Report, dated 01/07/2021, completed by the SBCH attending physician, noted R1’s primary diagnosis as anasarca, with secondary diagnoses of atrial fibrillation, anemia, GERD, and cirrhosis. The accompanying medication standing orders listed only over-the-counter medications to be taken as needed. The Pre-Placement Appraisal, dated 01/07/2021, also completed by the same SBCH physician noted that R1 had the following conditions and listed the medications that R1 was prescribed at that time: Aspirin for atrial fibrillation, Bumex for HFPEF and anasarca, Lactulose for cirrhosis, Protonix for GERD, Folic Acid for anemia, and Levemir and sliding scale Aspart for diabetes. An administrator for CCHHS stated sometimes hospital discharge records list all medications given to patients in the hospital, which are not necessarily meant to continue taking upon discharge. CCHHS personnel stated they did not have a list of medication from the hospital that says what medications R1 was to take upon discharge. CCHHS paperwork states per Cottage Health, “you have not been prescribed any medications.” Continued on 9099-C However, upon further investigation CCL located a medication discharge list on the Interfacility Transfer After Visit Summary from Cottage Hospital, that neither the facility nor CCHHS had in their possession. The Interfacility Transfer Medications included Bumex to be given twice daily from 01/07/2021 at 9:00pm until discontinued, insulin aspart pen injection 0-10 units to be given on a sliding scale four times daily and nightly from 01/07/2021 at 12:00pm until discontinued, and insulin determir pen injection 15 units to be given daily from 01/08/2021 at 9:00am until discontinued, among other medications. On 01/13/2021, CCHHS completed their initial assessment of R1. R1’s primary diagnosis was COVID-19 acute respiratory disease, but other diagnoses included type 2 diabetes mellitus without complications, hypertension, and hyperlipidemia. R1 was noted as being diabetic without insulin dependence. R1 was also noted as not taking any medication with the exception of over-the-counter and herbal medications. CCHHS had orders for skilled nursing, physical therapy, and occupational therapy. There were also orders for social work because R1’s resident representative was concerned that R1 was not prescribed the correct medications at the facility. The facility reported R1 was consuming smoothies alone, so CCHHS ordered a nutrition evaluation because of R1’s decreased appetite and weight loss. The facility reported R1 was only eating twice a day. R1’s physician orders called for a low carb diet with no concentrated sweets. During the skilled nursing visits on 01/13/2021, 01/20/2021, 01/26/2021 and 01/27/2021, staff reported to the nurse that R1 had bowels movements on those dates. Physical therapy was attempted with R1 on 01/15/2021 and 01/20/2021, but R1 resisted and refused. On 01/21/2021, R1 was assigned a new PCP and had a tele-health visit with R1’s resident representative to review R1’s recent hospitalization, recent events, as well as past medical history and goals of care. PCP was aware that R1 was “apparently not receiving any medication as listed on the physician’s report”. Following the tele-health visit, PCP ordered a speech therapy consult and an order for an RN to check R1’s vitals and to report R1’s blood glucose. On 01/28/2021, PCP ordered for CCHHS to call R1’s family member “to assist with lab draw if patient uncooperative”, and prescribed Bumex along with over-the-counter medications. Continued on 9099-C On 02/01/2021, staff found R1 on the floor in their bedroom. R1 was assessed for injuries and 911 was called due to R1 complaining of pain. Emergency Medical Services (EMS) arrived at 3:57pm and transported R1 to SBCH. R1 was hospitalized at SBCH for evaluation of bruising and swelling to the left upper chest. Chief complaints were abrasions as a result of the fall out of a wheelchair. Medics reported a blood glucose of 499. Per hospital records, skin tears and ecchymosis were noted to bilateral forearms. Medics also reported R1 does not take any prescription medications. R1’s diagnoses included sepsis due to a urinary tract infection (UTI), hematoma of the left chest wall, acute retention of urine, and stage 3 chronic kidney disease, among other conditions. A CT scan was taken of chest, abdomen, and pelvis showed a large anterior left chest wall hematoma without associated fracture, moderate stool burden throughout the colon correlates for constipation and predominately sub-diaphragmatic/perihepatic ascites on the right, which was new compared to the previous study and is of unknown etiology. R1 had clinical signs for dehydration that included dry mucous membranes, tachycardia, and abnormal vital signs. R1 required a large volume of rapid fluid resuscitation through IV. R1 had urinary retention that was alleviated when a Foley catheter was inserted and drained greater than 1500 cc of urine. This was consistent with an infection and was confirmed by R1 having an elevated white blood count, procalcitonin, and lactate levels. Antibiotics and fluids were ordered along with 10 units of insulin. On 02/02/2021, R1 was discharged to home and placed on hospice. The medical records reviewed indicate that R1’s sepsis resulted from a UTI. The SBCH treating physician advised that R1’s sepsis was caused by a UTI that may have been caused in part by effects of unmanaged diabetes. The facility failed to notice R1’s diabetes diagnosis, which was clearly listed on R1’s pre-placement appraisal at the time of admission to the facility on 01/07/2021. The former facility administrator stated that R1 had no prescriptions at the time of admission, but had the facility known that R1 required insulin, as is indicated on the pre-placement appraisal, the facility would not have admitted R1 without home health in place for a nurse to administer it. Continued on 9099-C It was clear from the 01/07/2021 hospital discharge documentation that the attending physician intended for R1 to have regular labs, and these recommendations were sent to CCHH at the time of hospital discharge. For reasons unknown, home health did not initiate home health services until 01/13/2021, which was nearly a week after R1’s facility admission. R1’s resident representative raised concerns at least by 01/15/2021 that R1 was perhaps not receiving their intended medications and the Memory Care Director agreed to look into the situation. However, the Memory Care Director had no recollection of this conversation and admits that she made no follow up. R1 did not have a primary care physician (PCP) to prescribe medications, and it was not until 01/21/2021 that R1’s new PCP saw R1. PCP prescribed several of the medications the SBCH attending physician had recommended for R1 (with the notable exception of insulin) on 01/28/2021. Ultimately, the facility had the responsibility to follow up on the medication discrepancy once R1’s resident representative advised that there was an issue. Additionally, the administrator should have noticed the discrepancy between diabetes and insulin listed in the preadmission appraisal, and the fact that r1 had no prescribed routine medications. Since the facility failed to do so, this likely contributed to the medical problems that manifested on 02/01/2021 since R1’s several chronic conditions were, in effect, not being treated from 01/08/2021 to 01/27/2021. The allegation that R1 became septic as a result of facility neglect in part because of the facility’s failure to help secure appropriate medications in a timely manner is therefore Substantiated at this time. The Cynthia Garcia was informed that the case will be reviewed and it is possible civil penalties could 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, appeal rights discussed, and a copy of this report issued.