Inspector’s narrative
What the inspector wrote
Additionally, S1 stated all staff started to give R1 Ativan (Lorazapam) and Morphine at nighttime when R1’s Haldol was discontinued in August 2022. LPA Ascencio conducted an interview with Hospice Nurse on 07/ 21/2023, starting at 11:35 a.m., who indicated that they did not have any concern regarding medication at the facility. Furthermore, Hospice Nurse indicated that they felt the staff was responsive and always communicated with the hospice agency regarding R1’s night behaviors.
File review for R1 was conducted on 07/21/2023 and revealed that on 03/11/22, R1 started Ativan (Lorazepam) .05 mg every four (4) hours as needed for agitation and anxiety not to exceed 3 mg in 24 hours and Seroquel (Quetiapine Furmate) 12.5 mg, take 1 tablet two (2) times a day. Further file review revealed that on 05/05/2022, Seroquel was discontinued, and R1 started on Haldol 2mg twice (2) a day for agitation and increased Ativan to 1mg every four hours routinely. Additionally, a review of R1’s Medication Administration Record (MAR) revealed that for all of May 2022, Ativan, which became routine on 05/05/2022, was not documented as self-administered, Haldol was documented on the MAR, Seroquel was discontinued and all other routine medication R1 was taking, was documented. In June 2022, Seroquel was documented to be discontinued; Ativan, marked as PRN in the MAR, was not documented or given routinely per 05/05/2022 routine orders, Haldol, was not added to the MAR and is unknown if medication was self-administered, all other routine medication was documented on the MAR. July 2022, Ativan, routine medication order as of 05/05/2022, was documented only twice, July 14
th
and July 15
th
, while Haldol was not documented on the MAR. All other routine medication was self-administered. Lastly, August 2022, Haldol was documented as being self-administered until August 9
th
, Ativan, routine order since 05/05/2022 was not documented and all other routine medication was self-administered.
Interview with R1’s Family Member, on 08/31/2023, revealed a text message that was sent to R1’s Family member from facility staff. Text message details that on June 3
rd
, 2022, at 6:00 p.m., R1 was given 2mg Haldol for increased restless and agitation. On June 4
th
, at 3:09 a.m., due to increased confusion and agitation, R1 was given 1mg of Haldol. At 4:00 a.m., R1 was given 1mg of Haldol. At 5:00 a.m., because of agitation, R1 was given 1mg of Haldol. At 6:00 a.m., R1 was given the 2 mg of Haldol.
Although R1 was taking Haldol and Ativan routinely for agitation, staff gave R1 additional medication outside of R1’s routine order on the morning of June 4th. Additionally, MAR review indicated that all routine medication was self-administered for the months of May, June and July 2022. However, Ativan was changed on 05/05/2022 to routine, this medication was not indicated in the MAR’s for May, June and July 2022.
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Additionally, Haldol was given during night time when it was not indicated in R1's orders. Based on evidence gathered, the allegation of facility staff did not give resident medications appropriately and timely is deemed substantiated at this time.
Lastly, regarding the allegation of facility did not have sufficient staff to meet the needs of the resident. Interview with R1’s Family Member on 08/31/2022, revealed that they paid for additional night services for R1. Licensee Adelaida Cruz informed R1’s Family Member that because the facility has three (3) care givers, they will be able to provide that additional caregiver for R1 at night. R1’s Family Member stated this changed only lasted about one (1) month up until May 2022 because 1 staff member was on vacation all of June and July 2022. Lastly, R1’s Family Member stated they received a refund from Licensee Cruz regarding the additional care staff oversight during night hours. Interview with staff members on 08/31/2022 and 07/24/2023, revealed that R1 required more care at night that the other residents. That same day, 08/31/2022, interview with Licensee Cruz confirmed what staff stated. Additionally, Licensee Cruz stated that the refund was done due to R1’s not needing care or supervision at night for June and July 2022. However, text messages proved by R1’s Family Member revealed that on June 4
th
, June 6
th
and several nights in July 2022, R1 would be awake at various times agitated needing constant redirection and medication interventions. Further text messages revealed, that in July 2022, there was only two (2) care staff available at the facility and only 1 care staff at night. Licensee Cruz stated in the text messages that they will not hire an additional staff, the 2 staff members were alternating night care with only 1 present at night and that R1’s family will received a refund accordingly.
Due to R1’s dementia diagnosis and constantly being agitated and exit seeking during night hours, R1’s Family Member spoke with Licensee Cruz to provide R1 with additional caregiver at an extra cost. Although R1’s Family Member received a refund for services they paid for in June and July of 2022, the fact the R1 needed additional supervision, based on text message and staff interviews, during night time and the refund that was provided reveals that Licensee Cruz could not fulfill the wishes of R1’s family by not providing that additional care and supervision to R1. Thus, the allegation of facility did not have sufficient staff to meet the needs of the resident is deemed substantiated at this time.
Pursuant to Title 22 of the CA Code of Regulations, the following
deficiencies were cited (refer to LIC 809-D):
Exit interview conducted. A copy of the report and appeal rights were provided.
