complaint·December 5, 2024

Based on the staff (S1, S2, S3, S4, and S6) interviews conducted on 10/30/2024 and 12/02/2024 with (5) staff members, Resident (R1) didn’t have a bowel movement for a few days. Doctors ordered to give him a suppository. R1 asked about the suppository and ok’d to be given the suppository. PDA (Private duty aid) was present with the R1. There was no restraint used. R1 was cooperative. The nurse (S3) asked for a CNA (S4) assigned to help. Staff got R1 on his side. R1 didn’t complain. Staff lifted R1’s leg and the suppository was given. R1 was advised that they should stay in bed for an hour or so. S3 and S4 don’t remember the nurse (RP2) alleging the incident was present in the room. RP2 was going under orientation and was a new employee there. Based on the private caregiver (PDA) interview conducted on 12/02/2024, PDA stated that S3 and S4 asked R1 if it was ok to put the suppository since R1 didn’t have bowel movements for almost 3-4 days. R1 asked what this was for and what was being done. S3 explained what they were going to do and explained they wanted to put this on their back. R1 said OK, then S3 put the suppository. S3 asked the resident to turn to the side facing the window. It helped R1 with the bowel movement and relieved the constipation. R1 was cooperative. Only S3 and S4 were present and RP2 was not in the room when the suppository was administered. R1 didn’t complain of any pain or discomfort during the procedure. Nothing unusual happened. If the abuse was there, PDA would have told their agency and R1’s family. Based on the R1’s family member (FM1 and FM2) interview conducted on 11/13/2024, FM2 stated that they have a 24x7 thread with their caregivers. They weren’t aware that this happened. Staff would know if any boundaries were pushed. If this incident happened, FM2 would be 100% certain that they would be pressing charges. PDA staff is very cautious. They all understood if anything became a problem, they would be there within 15 minutes. They will call us, and they know that. Violation cannot happen. Nurses would have informed us. They didn’t even allow sleep medicine that was not allowed by the doctor. Regarding the allegations that Staff are not following reporting requirements, Reporting Party (RP) stated that Jean was told by Jing not to document the restraint. Based on the staff (S1, S2, S3, S4, and S6) interviews conducted on 10/30/2024 and 12/02/2024 with (5) staff members, detailed notes are documented in R1’s progress notes, and suppository and medications administered are documented in Medical Administration Record (MAR). Continued on LIC9099-C Based on the R1’s family member (FM1 and FM2) interview conducted on 11/13/2024, FM2 stated that the facility documents everything even if any fall happens. Based on the records review conducted on 11/13/2024, the facility documented the suppository administered in the Medical Administration Record (MAR), given at 8:06 PM on 09/22/2024 for constipation. The Progress Notes indicated that R1 was alert and verbally responsive. All due meds were given and tolerated well by R1. PDA was in the room on standby to assist with need. Based on observations, interviews conducted with staff members, a private caregiver, and family members, and records reviewed, the department has determined that although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted. A copy of this report was discussed and left with the Neda Armanfar , Director of Assisted Living, whose signature on this form confirms receipt of this report.