other·August 12, 2022

The review of End of Day reports dated 12/26/2019 through 1/3/2020 noted on 12/26/2019, 12/29/2019, 12/30/2019, 01/01/2020, 01/02/2020, and 01/03/2020, multiple staff noticed blood in R1’s urine. On 01/03/2020, facility staff S1 noticed a discharge coming from R1’s penis and reported the concern to the nurse on duty, S2. S2 stated during interview to have told S1 to “keep an eye on it.” S2 stated to have forgotten to have made a report on the incident to S2’s supervisor before leaving work. On 01/04/2020, R1 had a fever and on 01/05/2020, when R1 stood up, blood, pus, and urine “gushed onto the floor.” R1 was taken to the hospital by the family member on 1/5/2020 and was hospitalized. R1 was diagnosed with traumatic hypospadias with fibrinous exudate at the meatus. Facility staff were unable to provide any evidence that R1’s condition was reported to attending Home Health agency or primary care physician. R1’s Physician’s Report and Appraisal/Needs and Services Plan indicate that R1 had been given a primary diagnosis of dementia. On 12/16/2019, the hospital discharged R1 to the facility with a catheter and discharge indicating arrangement with Home Health Agency for catheter care assistance once a week. In an email sent to the Department on 03/30/2022, staff S4 stated that the facility had no record of submitting an exception request for R1’s catheter. The Department did not receive any exception request on the restricted health condition for R1’s use of a foley catheter. Facility did not have a plan of care to address the resident’s pulling of the catheter which resulted in injury, infection, and hospitalization. Based on records review, interviews with staff and witnesses, and observations, there is preponderance of evidence to prove the alleged violations did occur; therefore, the allegations are substantiated. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $10,000.00 for violation Resulting in Serious Bodily Injury is pending review. Deficiencies were cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 9099-D. Report was discussed with Assistant Executive Director Preet Kaur. A copy of this report and licensee’s Appeal Rights forms were provided. Appeals must be directed to Licensing Regional Manager.