Complaint·May 5, 2021

Per the investigation, the facility implemented fall prevention measures as instructed by hospice. In addition, hospice had instructed the facility to provide R1 with Ambien to at bedtime to assist R1 with sleeping, which was indeed administered per the medication administration records. Whereas staff do not conduct status checks throughout the night, all fall prevention measures were in place, and S1 immediately responded once alerted to R1’s fall. However, even if status checks were performed every two hours while R1 was in bed, the investigation concluded that R1 could have attempted to get out of bed in between such checks. Based on the investigation, there is insufficient evidence to support the claim that lack of supervision resulting in resident falling and sustaining fracture. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff failed to notify residents family and physician of change in condition It was alleged that R1’s family and physician were unaware of the medication changes. A review of hospice documents and R1’s medication record indicated that R1 was prescribed Zolpidem (Brand name: Ambien) and alprazolam (Brand name: Xanax) by R1’s hospice attending physician on 8/20/2020. The zolpidem was prescribed to be given once every night due to R1’s insomnia and the alprazolam was prescribed to be given up to three times a day as needed for anxiety. It appeared that the two medications were a standing order from the time that R1 was admitted to the facility on hospice. Interviews and records review stated that a hospice representative was present during R1’s admittance to the facility on 8/20/2020, and that hospice recalled explaining the medication regime to the facility staff and R1’s family. Hospice notes reflected that there was discussion around ensuring that R1 does not take Ambien and Xanax together, to which the family and facility staff verbalized understanding. Based on interview and record review, a change of medication did not transpire during the time that R1 was in the facility from 8/20/2020 – 8/26/2020. The only change of condition throughout R1’s time at the facility was in terms of the fall from 8/26/2020, and the family and R1’s physician was notified of the fall. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. Signatures obtained. A copy of the report was provided to the Administrator. Regarding the allegation: Lack of supervision resulting in resident sustaining fracture It was alleged that R1 sustained a fractured left hip due to inadequate care and facility neglect. Records reviewed and interviews conducted confirmed that prior to R1’s admittance facility on 8/20/2020, R1 fell on approximately 8/1/2020. As a result, medical records revealed that R1 suffered a fractured right wrist and right hip pain. R1 continued to express pain in their right thigh, so a hospital visit on 8/10/2020 confirmed that R1 did not suffer any fractures of the right femur or hip. Yet, as R1 only complained of pain in the right thigh, there were no imaging records for R1’s left hip to assess whether there was a fracture or any injury. R1 was diagnosed with osteoarthritis and R1 was unable to bear weight on their right leg. R1 was admitted to this facility on 8/20/2020 and was concurrently admitted to hospice. A review of the hospice Plan of Care and facility appraisals confirmed that R1 was deemed a high risk for falls. In response, the facility implemented a fall mitigation plan. Hospice ordered a full bedrail, a floor mattress next to R1’s bed, and instructions for R1 to use a wheelchair or two-front wheel walker for ambulation. Staff were also instructed to lower R1’s bed to the lowest setting, which staff complied. Staff interviews revealed that on at least three occasions, R1 attempted to ambulate without the use of a walker or wheelchair, yet these instances did not result in a fall or injury. A review of medical records dated 8/18/2020 revealed that R1 tended to get up and wander, despite pain to their right hip. Similar observations were documented by hospice nurses whom would provide care for R1. Due to R1’s cognitive decline, hospice noted that R1 would attempt to get up as R1 truly believed they could ambulate without assistance. On the evening of 8/25/2020, Staff #1 (S1) and Staff #2 (S2) were on duty. S1 and S2 checked on R1 at least once during NOC shift and noted that R1 was asleep. At 4 a.m., S1 was awoken by R1’s call for help, and S1 entered the bedroom and saw R1 on the floor. At the time of the unwitnessed fall, the full-bedrail was on the bed; however, there was a gap between the end of the bedrail and the footboard which is about 10 inches wide, which is how staff assumed that R1 slid out of bed. S1 asked R1 if they were hurt, and R1 did state that their hip hurt. However, R1 did not specify if it was the left or right hip, so S1 assumed it was the right hip, which was an existing pain. R1 was put back to bed, and S1 did not call 9-1-1 or inform the Administrator as S1 did not think it was an emergency. The Administrator arrived at the facility at 8 a.m. and was notified of R1's fall. In the morning, R1 expressed pain, thus the Administrator called hospice and requested an x-ray. An X-ray of the left hip was taken at 11:40 a.m. on 8/26/2020 and it was then discovered that R1’s left hip was fractured. The Administrator called 9-1-1 at 4:55 p.m. R1 was admitted to the hospital at 5:26 p.m. and the x-ray showed that R1 sustained an acute, comminuted intertrochanteric left hip fracture. Regarding the allegation: Staff are overdosing residents It was alleged that R1 and the other facility residents were being overmedicated. A review of R1’s list of medications and R1’s medication administration record (MAR) indicated that medications were administered as prescribed. The LPA conducted a medication audit on 4/27/2021 at 9:36 a.m., and the LPA reviewed medications for the current six residents. Out of the six residents, the LPA observed that one out of six residents (R2) were receiving an extra dosage of medication. The prescription for the pain medication stated Take 1 capsule by mouth every 4 hours as needed for pain. Max 4 per day . A few of the medication administration record (MAR) for R2 revealed that R2 was receiving upwards to five pills per day. The Administrator confirmed that R2 requested additional medication and they were unaware that the max amount that should be given for the medication is four pills per day. Based on the investigation, whereas there is insufficient evidence to support the claim that R1 was overmedicated, there is a preponderance of evidence that one out of the six residents (R2) currently admitted to the facility is overmedicated. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's report and appeal rights were reviewed and issued. Signatures were obtained.