complaint·October 25, 2024

On 05/28/2024, from 11:11 a.m. to 2:30 p.m., LPA Z. Chochian conducted an initial 10-day complaint visit for the above allegations. Upon arrival, LPA Chochian met with the Executive Director (ED), Remon Pagels and explained the reason for the visit. During the visit, the LPA reviewed resident files and gathered information pertinent to the case. On 06/19/2024, from approximately 12:15 p.m. to 2:45 p.m., Investigator Ferris conducted interviews with the Executive Director (ED), staff and residents; on 07/15/2024, from approximately 12:45 p.m. to 3:30 p.m., with R1’s resident representative, attempted an interview with R1, and staff; and on 07/30/2024, at approximately 2:30 p.m., with R1’s Primary Care Physician (PCP) nurse. In addition, the investigator reviewed Los Robles Regional Medical Center hospital records, Affinity Home Health Resources records, and facility file documents related to R1 and the investigation. According to R1’s Physician’s Report, dated 09/19/2023, diagnoses included dementia with confusion and disorientation, aortic stenosis, and urinary incontinence with the ability to follow instructions, communicate needs, and was ambulatory, but unable to bathe self, dress or groom self, or care for own toileting needs. R1 was not prescribed any medications. A review of the Unusual Incident/Injury Report (SIR) dated 02/05/2024, noted R1 tested positive for COVID-19 and placed on 5-day quarantine in apartment. The SIR dated 02/10/2024, noted R1 was sent to the hospital for weakness and that R1 had not eaten in two days or drank any fluids. (During interviews, Staff #1 (S1) denied R1 stopped eating and drinking completely but clarified R1’s intake of food and liquids lessened after R1’s COVID-19 diagnosis and that was what was meant by their statement on the SIR dated 02/10/2024). The SIR dated 02/16/2024, noted R1 was transported to the hospital for confusion. A review of the facility meal attendance reports showed R1 ate on 02/05/2024, (02/06/2024 meal attendance report could not be located), 02/07/2024, 02/08/2024, 02/09/2024, (R1 was hospitalized on 02/10/2024 and returned on 02/15/2024) and was hospitalized again on 02/16/2024 without returning to the facility. The shower/bath log for February 2024, showed R1 was showered on 02/02/2024, 02/06/2024, 02/09/2024, and 02/16/2024. Report Continued on LIC 9099-C. The Los Robles Regional Medical Center (LRRMC) records documented, on 02/10/2024, R1 was brought in by ambulance from Atria Hillcrest for evaluation of generalized weakness and increased darkness of urine, onset two days ago. The notes documented R1 had advanced dementia who presented to the emergency department with a recent COVID-19 diagnosis. R1 was admitted for severe sepsis and complicated urinary tract infection (UTI). A malnutrition screen was conducted on 02/12/2024, noting in summary, the nutrition problem was inadequate oral intake and etiology was acute illness and chronic disease with no notations or concerns of neglect and/or lack of care. On 02/15/2024, R1’s Primary Care Physician (PCP) discharged R1 back to the facility. On 02/16/2024, R1 was re-admitted to the LRRMC hospital due to the chief complaint of mental status changes. The hospital notes document “Patient with dementia recent admission post COVID-19 with hypernatremia, AKI, and UTI who presents to the emergency room after discharge. Likely toxic metabolic encephalopathy from UTI and recent hospitalization in setting of advance dementia. Urinalysis is still positive, started Cefepime. Oral intake is adequate, and labs are stable.” On 02/20/2024, R1 was discharged to a skilled nursing facility with a discharge diagnosis of dementia, acute encephalopathy, altered mental status, and history of COVID-19. On the allegation Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) which resulted in R1 developing sepsis from a urinary tract infection while in quarantine for COVID-19. The Department’s investigation did not provide sufficient evidence to substantiate neglect/lack of care. Staff interviewed stated R1’s adult diaper was changed on a regular basis and R1 was checked every two hours. Staff also stated R1’s urine had a strong odor, and R1 was tested for a urinary tract infection with negative results, but they were unable to provide documentation to confirm this information. Affinity Home Health Resources medical records had no notations for concerns of neglect and/or lack of care. Los Robles Regional Medical Center (LRRMC) Hospital medical records had no notations concerning neglect and/or lack of care. Per R1’s resident representative there were no concerns with R1’s care prior to R1’s COVID-19 diagnosis and all issues resulted after R1’s diagnosis and while R1 had COVID-19. Per R1’s Primary Care Physician (PCP), it is possible COVID-19 was a causative factor of the sepsis diagnosis and no concerns of neglect and/or lack of care were reported. There is no evidence to conclusively determine the cause of sepsis, R1 was diagnosed with comorbidities including COVID-19, and there was insufficient evidence to support the allegation, therefore it is deemed Unsubstantiated at this time. Continued on LIC 9099-C. On the allegation Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) resulting in R1 becoming malnourished while in quarantine for COVID-19. The Department’s investigation did not provide sufficient evidence to substantiate neglect/lack of care. Daily meal records showed R1 was provided three meals on a daily basis and per the Executive Director (ED), R1 consumed the food due to no notations made on the meal records that stated otherwise. Staff interviewed stated R1 consumed the food R1 was provided and at no time was R1 denied access to food. Staff stated R1 was less hungry and thirsty during the quarantine but did eat and drink. No notations or concerns of neglect and/or lack of care were noted on the Affinity Home Health Resources medical records. According to LRRMC medical records, a malnutrition screen was conducted on 02/12/2024, noting in summary, the nutrition problem was inadequate oral intake and etiology was acute illness and chronic disease with no notations or concerns of neglect and/or lack of care. Per R1’s resident representative, there were no concerns with R1’s care prior to R1’s COVID-19 diagnosis and all issues resulted after R1’s diagnosis and during R1’s term with COVID-19. Per R1’s PCP, it is possible COVID-19 was a causative factor of the malnutrition diagnosis and no concerns of neglect and/or lack of care were reported. There is no evidence to conclusively determine the cause of malnutrition, R1 was diagnosed with comorbidities including COVID-19, and there was insufficient evidence to support the allegation, therefore it is deemed Unsubstantiated at this time. On the allegation Neglect/Lack of Care: Staff neglected or failed to provide an adequate level of care to Resident #1 (R1) resulting in R1 becoming dehydrated while in quarantine for COVID-19. The Department’s investigation did not provide sufficient evidence to substantiate neglect/lack of care. Staff interviewed stated R1 consumed the fluids R1 was provided and at no time was R1 denied access to fluids. Staff stated R1 was less hungry and thirsty during the quarantine but did eat and drink. Affinity Home Health Resources medical records had no notations of concerns for neglect and/or lack of care. No notations were made concerning neglect and/or lack of care on R1’s LRRMC medical records. Per R1’s resident representative, there were no concerns with R1’s care prior to R1’s COVID-19 diagnosis and all issues resulted after R1’s diagnosis and while R1 had COVID-19. Per R1’s PCP, it is possible COVID-19 was a causative factor of the dehydration diagnosis and no concerns of neglect and/or lack of care were reported. There is no evidence to conclusively determine the cause of dehydration, R1 was diagnosed with comorbidities including COVID-19, and there was insufficient evidence to support the allegation, therefore it is deemed Unsubstantiated at this time. Continued on LIC 9099-C. This report has been amended to remove allegation "Staff did not provide resident's records to authorized representative." Please refer to report dated 11/18/2024 for supplemental report. No citations issued. Exit interview conducted. A copy of today's report was provided.