complaint·October 1, 2024

There may also be instances, that staff could ask a resident if they could wait until the next pain medication window. When a resident cannot wait, staff will contact hospice for direction on administering breakthrough pain medication. Facility policy is to review the electronic MAR to ensure an additional dose is permissible. Bowman stated that if a Med Tech is advised that a resident is in pain, they would typically speak to resident and follow policy. On August 8, 2024, newly hired Med Techs were in training and may not have known how to explain pain management procedures and policies. A request for copy of July and August e-MAR was made on 9/20/24 via email. LPA reviewed the MAR for R1 and observed that PRNs for pain were given during the months of July and August 2024. Bowman advised LPA that R1 is to receive Norco 4 times a day routinely as needed. R1 also has a comfort kit consisting of Lorazepam and Morphine to be used at the time of her passing. LPA reviewed physician’s report that states R1 to avoid aspirin and NSAIDS. LPA interviewed R1 about their pain management. R1 stated they were in pain yesterday and the day before they were not. R1 stated, “I’m feeling so lousy”. R1 stated that there are days Staff provide medication for pain and on other days Staff will not provide medication for pain. R1 visibly confused. R1 could not recall if they had eaten that day and made various statements; “I’m ready to leave, I’m hanging, I’m ready to give up, I’m so tired of it now, I’m 96 and I’m at the very end of my rope”. At the time of this report, R1 has passed away. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. LPA interviewed R1 about their experience with staff assistance during meals. R1 was unable to provide any insight into LPA questions. It was alleged staff did not reposition R1 in their bed during mealtime. LPA reviewed R1’s physician’s report and care plan, which indicates R1 is non-ambulatory and has motor impairment and paralysis. LPA observed R1 was able to slightly adjust themselves in bed and from LPA observation it was clear that R1 required additional assistance. Bowman described a separate incident on 8/8/24. S2 entered R2’s bedroom and advised they were not trained and did not know how to change and reposition resident. R2’s daughter was present and notified Bowman of the incident. Bowman stated that this was not the first instance of S2’s failure to perform duties. S2 was terminated effective 8/12/24. Based on the multiple accounts by multiple staff, it is reasonable to believe that a staff member was not repositioning residents and was ultimately terminated. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC 9099D. Exit interview conducted, copy of report issued.