Complaint·December 19, 2024

Facility Notes indicate R1 suffered unwitnessed falls in her bedroom on the following dates: - On 09/01/2024 at approximately 1958 hours, R1 was found on the floor lying on her right side on the fall mat. She complained of pain to her shoulder and right side of hip. No other injuries were visible. She was assisted to her bed and provided with pain medication. - On 06/03/2024 at approximately 2245 hours, R1’s bed motion sensor went off and R1 was found on the floor curled up on her left side. She had a large skin tear and complained of pain. R1 was transported to the hospital to be medically assessed. - On 05/10/2024 at approximately 2200 hours, R1 was found lying next to her bed. An assessment was completed, and no new injuries were located. R1 was assisted back to her bed. - On 05/04/2024 at approximately 0920 hours, R1’s bed motion sensor went off. Staff responded and found R1 on the floor. R1 stated she was trying to walk to the restroom and fell. She complained of pain to her back and left hip. R1 was transported to the hospital to get medically assessed. - On 05/03/2024 at approximately 1500 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on her buttocks on the right side of her bed. R1 was assessed and no new visible injuries were noted. R1 did not complain of any pain. She was placed in her wheelchair and taken out into the hallway. - On 03/22/2024 at approximately 0115 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on the floor next to her bed. She was assessed and her left wrist was swollen and discolored. R1’s left arm had some deformities. She could not remember how she fell. R1 was transported to the hospital to be medically assessed. - On 03/22/2024, at approximately 1530 hours, R1’s bed motion sensor went off. R1 was found sitting on the bathroom floor. No injuries were noted. R1 was assisted onto her wheelchair and brought to the main lobby. - On 02/26/2024 at approximately 1500 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on her buttocks next to her bed. She was confused and disorientated. Staff attempted to place R1 back in her bed. However, R1 refused to. R1 attempted to stand up frequently despite the staff’s redirections. R1 was brought to the common areas for closer staff supervision. - O n 11/13/2023 at approximately 2007 hours, R1 suffered an unwitnessed fall in the facility’s hallway. Staff observed her sitting on the floor beside her walker. R1 complained of minor pain in her buttocks. She was placed on her bed and provided with pain killers. - On 08/22/2023 at approximately 2207 hours, R1 suffered an unwitnessed fall in her room and was found sitting on the floor. R1 denied any pain. She was assisted to her bed and the bed motion sensor was reset. Hospice Agency Records: On 06/06/2024, R1 was admitted to hospice with a multitude of diagnoses. R1 was given a life expectancy of six months or less if the terminal illness ran its normal course. Per the most recent records, from 08/28/2024 to 09/06/2024, no respiratory distress was noted on R1, and her vitals were stable. Hospital Records: On 03/22/2024, R1 was admitted to an acute hospital regarding a fall she suffered at the El Rio facility. A medical assessment was completed, and R1 was found to have a fracture on her left wrist. On 05/04/2024, R1 was admitted to an acute hospital regarding a ground-level fall she suffered at the El Rio facility. She was found on the floor for an unknown period of time and her bed motion detector was off. A medical assessment was completed, and she was found to have a fracture of the thoracic vertebrae. R1’s blood pressure was low, and she was severely dehydrated with an acute kidney injury. R1 was confused, agitated, and aggressive towards medical staff. On 05/30/2024, R1 was admitted to an acute hospital regarding rectal bleeding. A colonoscopy was done which showed no bleeding on her ulcers. She was discharged on 06/03/2024 and returned to the El Rio facility. Later that day, at 2347 hours, R1 was re-admitted to the hospital regarding a recent unwitnessed fall she suffered at the El Rio facility. She complained of pain to her left arm. A medical assessment was completed, and no acute fractures were found. Due to her physical condition deteriorating, and her recent falls, R1’s daughter decided to release R1 back to the El Rio facility under hospice services. Interviews: During the course of a interview with a former staff member that is a Licensed Vocational Nurse (LVN), the LVN stated that the facility is understaffed and the staff are overworked and if the facility had the proper staff to client ratio, some of these incidents could have been prevented if staff had the time to conduct appropriate checks on the residents. The LVN said even though staff checked the staff log indicating they had checked on a resident, such as R1, the interviewee believed some staff did not conduct their hourly checks on time based on the amount of work and responsibilities they had. The LVN also said she believed R1 was dehydrated because staff did not have time throughout the day to encourage R1 to drink her liquids. The LVN said the reason she stopped working at the El Rio facility was due to the facility being poorly managed, understaffed, the staff being overworked and unable to provide the proper care and supervision for the residents. During the course of an interview with a current Resident Assistant (RA) the RA stated there were a few months when the facility was short staffed and unable to complete all the required tasks; including provide the appropriate care and supervision to all the residents. During that period, staff did not have the time to encourage residents to drink their water throughout the day. Allegation 1: Resident sustained multiple falls in the facility resulting in multiple injuries Resident 1 (R1) suffered approximately 9 unwitnessed falls while in care at the El Rio Memory Care facility, some resulting in fractures. Facility staff reported R1 was prone to falling due to R1’s mental and physical condition. To prevent or diminish the number of falls, facility staff indicated they provided R1 with a half-rail bed, a motion-sensor bed adjusted to higher sensitivity, a “fall mat” and constant staff supervision. Most of the staff reported R1 was to be checked every hour. The staff Hourly Check log indicates these checks were conducted every hour or longer. However, R1’s Facility Service Plan and Resident Assessment indicate R1 required staff checks every 30 minutes. Staff reported that for a few months, the facility was short-staffed and unable to complete all the tasks and provide proper resident care and supervision, including 30-minute checks. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means the preponderance of evidence standard has been met. Allegation 2: Facility's neglect and lack of care failed resident resulting in resident being hospitalized due to severe dehydration On 05/04/2024, R1 suffered an unwitnessed fall for which required hospitalization. A medical assessment was completed, and R1 was diagnosed with acute kidney injury due to severe dehydration. An ‘acute’ illness means the illness developed recently. Facility staff reported R1 ate most of the meals given but refused to drink all the water provided. Some staff said that throughout the day they provided residents with water and encouraged them to drink it. However, other staff reported that for a few months, the facility was short staffed, and they were unable to complete all the tasks and provide proper resident care and supervision. This included encouraging residents, such as R1, to drink their water throughout the day. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means the preponderance of evidence standard has been met. Allegation 3: Staff did not follow resident’s care plan. Facility staff reported R1 was prone to falling due to R1’s mental and physical condition. Most of the staff reported R1 was to be checked every hour. The staff Hourly Check log indicates these checks were conducted every hour or longer. However, R1’s Facility Service Plan and Resident Assessment indicate R1 required staff checks every 30 minutes. Staff reported that for a few months, the facility was short staffed and unable to complete all the tasks and provide proper resident care and supervision, including 30- minute checks. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) and/or the Health and Safety Code. Civil penalties are also being assessed in the amount of $1500.00. At this time civil penalty assessments are under review and additional civil penalties may be assessed pursuant to Health and Safety Code 1569.49. An exit interview was conducted and a copy of this report was given to Executive Director Theresa Pettapiece. A registered nurse (RN) arrived to assess R1 and R1 denied having any pain. R1 was pleasant and could not recall the fall. Vitals were within normal range. No new bruising noted. The RN spoke with R1's daughter and hospice and provided an update at 23:58. Based on the Hospice agency’s own documentation the hospice agency was notified of the unwitnessed fall in a timely manner therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report was given to Theresa Pettapiece. proper food service, staff cannot force a resident to eat. Based on LPA Jensen's observations and interviews conducted the allegation of " Staff did not ensure resident was provided proper food service" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence doesn't prove it. Allegation 2: Staff did not meet resident’s toileting needs in a timely manner. Hospice records for Resident 1 (R1) note that R1 was observed to be clean and dressed. The medical records for R1 do not show any skin breakdown where a brief would be worn. There were no medical records reviewed diagnosing urinary tract infection. The facility has an incontinence plan that is in compliance with regulatory requirements. No residents interviewed complained that their toileting needs are not being met. Based on the above listed factors the allegation of "Staff did not meet resident’s toileting needs in a timely manner " is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence doesn't prove it. An exit interview was conducted and a copy of this report was given.