complaint·June 28, 2021

Facility fall documentation indicated the authorized representative was informed about fall incidents. Also, LPA Martinez reviewed R1's fall history and fall prevention documents. The facility implemented a fall prevention plan, which included the following: fall motion sensors, E-cord next to R1's bed and in private bathroom, hourly checks, hospital bed, and fall floor mat (breaks fall/soften fall). Based on the facility documents R1 refused to use her cane all day on 12/19/2018. The facility 9/11/2019 Bi-Monthly assessment reported R1's gait is not stable, however, R1 will not use a walker. Additionally, on 12/29/2019, R1 refused to wear a back brace. Furthermore, LPA Martinez learned the facility documented 6 falls during the period of 2018 to 2020. The last fall documented was on 12/24/2019; R1 ambulated independently in her room and tripped over a chair. R1 was sent out to the hospital on 12/24/2019. While at the hospital, R1 was diagnosed with back pain, and a CT head scan was negative. Furthermore, 12/24/2019 hospital records documented a past vertebra L2 fracture. LPA observed the 12/06/2018 LIC 602, Physician's report for residential care facilities for the elderly (LIC 602). The LIC 602 dated 12/06/2018 stated L2 vertebra fracture. In addition, facility Nursing Evaluation/Data Collection document dated 12/6/2018 stated vertebral fracture, and the 12/29/2019 LIC 602 stated vertebra fracture. A 12/24/2019 hospital record stated, "advanced dementia with failure to thrive". The 12/24/2019 hospital record also reported per family, R1's general health condition had been slowly declining. During the hospitalization, hospice was initiated. R1 was discharged to El Rio Memory Care on 12/29/2019. It was learned shortly after the initiation of hospice, R1 began transitioning. It was also learned R1's primary cause of death was respiratory failure secondary to senile degeneration of the brain. Based on the investigation, El Rio Memory Care facility implemented a fall prevention plan for R1, Also R1 was diagnosed with a back fracture prior to moving into El Rio Memory Care. Moreover, facility fall incident reports indicated R1's authorized representative was informed of falls. It was also learned that R1 was receiving pressure injury care from Seva Hospice and facility staff, and there were no concerns about the care be given. In addition, there was not a preponderance of evidence to substantiate questionable death allegation due to declining health, and hospice notes indicating R1 began to transition shortly after initiation. Continued... Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. There were no deficiencies cited, and an exit interview was conducted. A copy of this report was given to Mary Keaton.