Complaint·May 10, 2024

On 12/26/2023, resident (R1) began to develop flu-like symptoms. R1’s responsible party was made aware. The review of records shows that on 12/26/2023 around 11:00PM, R1’s responsible party contacted the facility to follow-up on R1’s condition. R1’s responsible party instructed the facility staff to monitor R1’s condition as R1 was not feeling well. It was noted during NOC shift that R1 had on and off coughing and was not feeling well but slept through the night. On 12/27/2023, between 6:30AM – 7:00AM, staff observed resident was sleeping. Around 8:00AM, staff checked R1. At 9:00AM, staff contacted R1’s responsible party regarding R1’s condition. R1 was observed to be wheezing, had a runny nose, and coughing. R1’s responsible party was stated to be on the way to the facility within an hour. Record review shows that after the telephone call to R1’s responsible party staff offered R1 breakfast, which R1 initially refused. Staff (S8) offered R1 yogurt and water, which R1 partially consumed prior to taking his/her medications. R1 was observed to be responsive but weak. Around 10:00AM, R1’s responsible party arrived to the facility and observed R1 laying in bed, unresponsive, and pale in color. R1’s responsible party contacted emergency services and R1 was then transported to the hospital. 8 staff members were interviewed. 5 out of 8 staff interviewed were familiar with R1’s care. 1 out of 5 staff members stated the observation of R1 looking weak the night before he/she went to the hospital (12/26/2023). 5 out of 5 staff stated the observation of R1 feeling unwell the morning of 12/27/2023. Based on interview, staff did not offer to contact emergency medical services when the initial telephone call was made to the RP. Staff stated they did not offer to contact medical services because RP stated to be on the way. The review of medical records shows that upon arrival of emergency medical services, R1 had an altered level of consciousness, shortness of breath, and a fever. R1 was hospitalized and diagnosed with a life-threatening infection and virus. PAGE 2 OF 3. On 12/26/2023, resident (R1) began to develop flu-like symptoms. Around 6:00PM, R1’s responsible party spoke with R1 who only speaks another language but English. R1 told his/her responsible party that his/her head was hurting all day and was not feeling well. The responsible party contacted staff and requested to dispense a PRN medication for R1. R1’s responsible party arrived to the facility about 45 minutes after the telephone call, and was informed by R1 that he/she has not yet received their PRN medication. Based on record review, the physician’s order for R1’s PRN medication states an instruction for “as needed”. R1’s PRN medication was dispensed around 8:00PM on 12/26/2023. Throughout the investigation, 3 witnesses were interviewed. 3 out of 3 witnesses denied recording a resident without consent. 3 out of 3 witnesses denied the observation of another visitor recording a resident without consent. 7 out of 7 staff members interviewed denied the observation of a visitor recording a resident without consent The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. A case management visit was conducted due to a violation observed. See LIC809 on 05/10/2024. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report was provided. Throughout the investigation, 7 staff members were interviewed. Based on interview, 6 out of 7 staff members stated R1 receives showers during his/her shower schedule days. 1 out of 7 staff members was not familiar with R1’s care as R1 was assigned to another group. S1 stated that staff were instructed to wait until R1’s family member arrived before staff could assist R1 with showers. S1 states that sometimes R1 needed to wait to be assisted with a shower if staff were busy assisting other residents. The review of records indicates that R1 is scheduled for showers three times a week. 7 out of 7 staff members interviewed denied restricting any visitors in the facility. 7 out of 7 staff members denied restricting any areas of the facility for visitors. Throughout the investigation, 3 witnesses were interviewed. 3 out of 3 witnesses denied being restricted visitation at the facility. 3 out of 3 witnesses denied the observation of any areas of the facility being restricted for other visitors. The review of records indicates that from October 2023 – December 2023, R1’s care was increased to a total of 65 acuity points and 61 billable points. Care items that were increased from October 2023 – December 2023 included grooming, toileting, assistive devices, outside providers, restless behaviors, verbally disruptive behaviors, delusions and hallucination behaviors, and disturbed sleep behaviors. 7 out of 7 staff members were interviews. Based on interview, R1 required total care and full assistance with activities of daily living (ADL) care. The Department has investigated the above allegations. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report was provided. The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. An immediate civil penalty of $500 is being assessed today for serious bodily injury. Additional civil penalties are pending review. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report and appeal rights were provided. PAGE 3 OF 3.