Inspector’s narrative
What the inspector wrote
Page 3 of 3.
On 11/30/2023, the Department interviewed Staff (S1) who stated R1 preferred female caregivers and staff including Med-Tech would check on R1’s wet undergarments. On 12/19/2023, the Department interviewed staff (S2) who stated residents are checked every 2 hours and every 30-60 minutes if the residents prefer to stay in their room. S2 stated that during the day, there are 6-7 facility staff monitoring residents in the common area, which include 3-4 caregivers. Based on staff schedule from 8/13/2023 – 8/26/2023, there were 4 caregivers on schedule for AM shift (6am-2pm), 3 caregivers for PM shift (2pm-10pm) and 2 caregivers in NOC shift (10pm-6am).
Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Greg Becker and a copy of the report was provided.
Page 2 of 3.
Based on record review of R1’s Needs and Services Plan dates 2/22/2023, R1 needs total assistance for toileting, uses undergarments and R1 requires physical assistance with part of toileting tasks as well as daily skin checks due to skin condition to the groin/peri area. Based on Resident’s Care Summary, R1 was being assisted with frequent or unscheduled incontinence care, assistance with toileting for more than 3 times per day, which included bladder and bowel care.
On 11/15/2023, the Department interviewed with Assisted and Independent Living Resident Services Director (AL/IL RSD), who stated most resident normally spend time in the living room, but if residents are in their bedrooms, then staff check on the residents hourly to assist with incontinence care. AL/IL RSD stated R1 required full assistance with incontinence care.
Based on interviews conducted with staff (S1-S4), staff stated R1 would use the bathroom toilet and would rarely soil the undergarment. Staff would check on R1’s undergarments at minimum 5 times during AM shift (6am-2pm), at minimum 5 times during PM shift (2pm-10pm) and as needed during NOC shift (10pm-6am). Staff stated R1 would ask to be assisted to go to the bathroom and staff would provide stand-by assistance. S4 stated R1 had one episode of rash in the peri area, but it was resolved after using ointment in the affected area for a day. Staff stated R1 would verbalize if undergarments needed to be changed. S4 stated the facility does not document every time R1’s undergarments were changed, but it was a standard practice for staff to change the undergarments when soiled and during every shift change. S4 stated R1 would not remain in wet and soiled diapers for an extended period of time, since R1 would verbalize when to go to the bathroom, or the staff were regularly checking on R1’s undergarments. S4 stated the R1’s responsible party will provide incontinence products every 2 weeks. S4 stated they are changing the resident every shift and every day to ensure R1 has dry undergarments and would go through R1’s supply of incontinence products regularly.
Page 2 of 4.
Based on investigation, it was not clear on which caregiver was assigned to R1 on the days he/she sustained falls and injuries, which were 6/3/2023, 6/9/2023 and 8/13/2023. Staff recalled R1 wearing a foam splint on his/her pinky finger for a while. Staff were unaware that R1 fractured his/her ribs until the Department confirmed R1’s injuries based on medical records. Staff did not recall on how R1 sustained a dislocated left pinky finger and fractured ribs on 6/3/2023. Staff believed R1’s finger injury was from R1 scooting his/her chair forward and scrapping the fingers underneath a table.
On 10/2/2023, the Department interviewed R1’s responsible party (RP). RP stated the first incident occurred on 6/3/2023. R1 sustained a hand injury when he/she was trying to sit down, and another resident (R2) pushed R1 out of the way. R1 was not seen by a medical doctor until 6/5/2023. An X-Ray was done on R1’s hand and ribcage since R1 complained of pain on the left ribcage. The results showed R1’s finger dislocated and R1 sustained injuries to the ribs.
On 6/9/2023, the second incident occurred where R1 had another fall at the facility. R1 was pushed by another resident to the ground. The third incident occurred on 8/13/2023 when R1 was punched in the face by another resident in the living room. R1 began hyperventilating and was nauseous.
On 12/14/2023, the Department interviewed the former Resident Services Director (RSD). RSD explained standby assistance is when staff will walk with the resident, supervising residents during showers or toileting, but the staff do not assist when residents are sitting down. RSD stated R1 fell one or twice when he/she attempted to use the restroom by himself/herself. R2 was sent out to the hospital for an evaluation but does not remember the specific date of when R1 fell. RSD stated that in April/May 2023, during dinner service, a resident pushed R1 out of his/her chair. RSD was not aware of R1 sustaining any injuries on his/her ribs or anywhere else but was aware that R1 sustained bruising to his/her left hand.
On 11/30/2023, the Department interviewed staff (S1), S1 stated that he/she did not recall what happened when R1 sustained injuries to his/her left pinky finger, he/she did not recall when it happened. On 12/19/2023, the Department interviewed staff (S2), S2 stated that R1 is a fall risk who utilized a walker with standby assistance. S2 stated that R1 is not combative and does not have any self-injurious behaviors.
Page 3 of 4.
S2 did not know what happened or how R1 sustained the finger dislocation or the fractured ribs from 6/3/2023. S2 stated he/she not aware of R1 was brought to the hospital and had a brace on his/her finger and not aware of an altercation R1 had with another resident in 6/9/2023. On 12/14/2023, the Department interviewed Staff (S3) stated R1 lost her balance a lot and was a fall risk and needed a caregiver with her but did not have 1:1 supervision.
On 11/15/2023, the Department interviewed with Assisted and Independent Living Resident Services Director (AL/IL RSD) who stated that staff is assigned to sit and supervise the residents but was unable to provide the names of staff who were assigned to provide care and supervise for 6/3/2023, 6/9/2023 and 8/13/2023. AL/IL RSD was also unaware of the 6/3/2023 and 6/9/2023 incidents.
Based on available information gathered on the incident which occurred on 8/13/2023 in the living room where R1 and R2 had a physical altercation. 3 facility staff members heard both residents screaming and did not observe the residents' altercation. One staff member (S4) was in the kitchen/dining room when he/she heard R1 and R2 screaming and went to the living room and separated the residents after R2 hit R1 twice and R1 hit R2 back. R1 sustained a small cut and swollen upper lip and R2 had a small bruising marks on the hand. There was no documentation of a staff being present at the time of the altercation in the living room.
A review of R1’s Physician’s Report dated 2/14/2023, R1 had a diagnosis of neurocognitive disorder and motor impairment/paralysis on the left side weakness and is confused/disoriented but does not have aggressive behavior. Based on record review of R1’s Needs and Services Plan dated 2/22/2023, R1 does not have current history of disruptive, aggressive, verbal or socially inappropriate behaviors. R1 needs protection and supervision because resident makes unsafe or inappropriate decisions. R1’s mobility and gait are limited and balanced is decreased with left sided paralysis and is able to ambulate with walker and one-person assist.
Page 4 of 4.
Based on the investigation, R1 was not reappraised after being involved in multiple physical altercations resulting in injury during the month of June 2023 and August 2023. Based on review of R1’s Progress Notes from 5/10/2023 – 8/22/2023, facility staff did not document any changes in physical functions and the appropriate assistance provided when observation reveals unmet needs.
Based on the investigation and review of Incident Reports submitted by the facility, the Department did not receive an LIC 624 Unusual Incident / Injury Report from the facility for the incident which occurred on 6/3/2023. Based on review of email from Executive Director on 6/27/2023, R1 “bruised her finger. We do not have to report it to licensing” referring to the incident which occurred on 6/3/2023. The incident on 6/9/2023 and 8/13/2023 were reported to the Department wherein R1 sustained injury/fall after resident altercation. Due to the injuries sustained while the resident is under facility supervision, a written report shall be submitted to the Department within seven days of the occurrence of the event. As stated in California Code of Regulation 87211 Reporting Requirements, any incident which threatens the welfare, safety, or health of any resident need to be reported to the licensing agency.
Based on interviews and record review of the facility, the preponderance of evidence standard has been met therefore the above allegations are found to be SUBSTANTIATED.
Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalties for the violation resulting in serious bodily injury is pending for further review.
This report was reviewed by the Executive Director, Greg Becker and a copy of the report was provided. Appeal Rights was provided.
