complaint·April 29, 2025

Questionable Death On the allegation of the questionable death of R1, it is the concern of the reporting party that the death of R1 is the result of the staff administering medication and not providing proper suctioning. To investigate the allegation, LPA Urena interviewed staff, administrators and the RP, and conducted record review. The record review revealed that R1 was receiving hospice services at the time of death. The Certificate of Death from the State of California indicates that R1’s immediate cause of death was Cardiopulmonary Arrest and terminal disease and condition (chronic kidney disease and congestive heart failure) resulting in death. No autopsy was conducted after death. Hospice records dated 11/14/2023, revealed that R1 had discontinued all curative treatments and had a terminal prognosis of six (6) months at the time of the report. Records review of the Medication Administration Record (MARS) used by the facility, indicated by the initials on the date of 03/17/2024, that S2 was the facility staff that prepared /administered the liquid Ativan (0.25ml) to R1, and that R1’s Representative administered liquid pain medication (Morphin 0.25ml). The interview with the RP revealed that on 03/17/2024 at approximately 3:00 p.m., R1’s representative found R1 in their bed in distress. R1’s representative was told by facility staff that R1 was unable to swallow the pain medication, which was due at 2:00 p.m. Facility staff stated to the representative that they were not skilled professionals and consequently could not administer the pain medication. The facility staff provided the pain medication to R1’s representative to administer to R1 at approximately 3:50 p.m. and after the pain medication was administered, R1 appeared to be relaxed. Furthermore, the R1’s representative stated that they were informed that R1 could not swallow and started communication with the hospice nurse in charge to ensure that R1 would continue to receive the pain medication as needed to keep them comfortable. At approximately 5:49 p.m. R1’s representative texted the hospice nurse of R1’s condition, letting them know that R1 is experiencing distress again due to gurgling their own saliva because they cannot swallow. Per R1’s representative, the hospice nurse in charge was out and did not have a reliable cell phone, consequently the hospice nurse in charge referred the representative to the hospice on-call nurse at approximately 6:00p.m. Continues on LIC 9099C pg.3 Pg. 3 Between 6:00 p.m. and 6:39 p.m. R1 started experiencing distress again (gurgling on their own saliva secretion). At some point during this time frame, the on-call nurse directed the facility staff (S1) to clear R1’s throat with sponges and to give R1 liquid Ativan (0.25 ml). Per R1’s representative, they watched “S1 clear out all this goo out of R1’s mouth with three different wet mouth sponges while R1 struggled in discomfort”. S1 cleared R1’s throat with at least three swab sponges and administered the liquid Ativan and left the room. S1 then tells R1’s representative, “to call hospice to tell them to send a nurse to clear out the ‘liquid’ from R1’s throat with a suction machine, the facility has the machine at the facility, but staff are not allowed to use it”. Per R1’s representative, a couple of minutes later, R1 started to throw up liquid, and was pronounced deceased. LPA Urena interviewed the staff (S1) about administering the liquid Ativan to R1 and S1 stated that they gave the medication to R1’s representative in an oral syringe to give to R1. Furthermore, S1 stated that they did not remember much about the incident, since it happened a year ago. LPA Urena interviewed staff 2 (S2) about the liquid Ativan, S2 stated that they prepared the oral syringe with the liquid Ativan, and they gave it to S1, but because they were not in the room, they are not sure who actually administered the medication to R1. On 04/25/2025, LPA Urena reached out to the Hospice agency’s nurse in charge and asked about the facility’s staff diligence in obtaining assistance for R1, and the Hospice nurse stated that the staff at the facility followed all instructions given to them by the hospice staff, and provided oral suction as instructed by hospice staff. Furthermore, R1 has a DNR/Polst and at no time did family requested for 911 to be called. Based on the information obtained through interviews and record review, R1 was experiencing distress due to pain and choking on their own saliva. Although S1, cleared R1’s throat with wet sponges and administered the liquid Ativan (0.25 ml) minutes before R1 was pronounced deceased, there is not sufficient evidence to prove that the medication or the clearing of the throat with wet sponges was the cause of R1’s death. R1 was receiving hospice care due to terminal disease. Furthermore, no autopsy was performed, and the Death Certificate lists the immediate cause of death as Cardiopulmonary Arrest, and to Chronic Kidney Decease. Although the allegation may have happened or is valid, based on the interviews, and record review; there is not sufficient evidence to prove the alleged violation did or did not occur Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted. A copy of the report was issued. Staff did not notify resident's responsible party of a change in condition. On the allegation that the staff did not notify the resident’s representative of a change in condition; it is the concern of the reporting party (RP) that the facility staff did not report directly to the resident’s representative about R1’s change in condition. The interview with the Administrators revealed that it is the facility’s policy that if a resident is receiving hospice services, the facility’s staff informs the hospice agency about the residents’ change in condition, and that the hospice agency in turn informs the resident’s representative. Per the Administrator, it is done in this manner because they feel that the hospice agency is better equipped to explain the changes and medical condition of the resident, to the residents’ representatives. The facility’s policy is an implied policy, and not part of the Admission’s Agreement policy. Record review revealed that the facility staff communicated with the hospice agency’s nurse about the change in condition (appetite/swallowing) of R1. The hospice staff communicated via text message with R1’s representative and vice versa about the changes in appetite and/or swallowing. The record review reveals that R1’s representative then communicates with the facility’s staff about the information received by the hospice nurse. However, the record review does not show direct communication between the facility Administrators and R1’s representative as a starting point about the observation of the resident and the changes in condition. Although the facility’s implied policy is that the hospice agency staff will communicate with the resident’s representatives, the policy was not found as part of Admission’s agreement or any other policy; furthermore, it does not supersede CCR regulations. Record review revealed that the care givers staff and the administrative staff initially communicated with the hospice nurse, but not with R1’s representatives. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.