complaint·March 18, 2022

(continued from page 1; 9099) On 09/02/2020, between 4:47 p.m. and 6:40 p.m., LPA Dulek conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with Resident Care Director Sara Gutierrez. The LPA conducted an interview and physical plant tour with the Resident Care Director at 5:27 p.m. and reviewed the pendant/resident call system at 5:36 p.m. The LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required. On 11/04/2021, LPA Camara conducted an unannounced subsequent complaint visit. LPA met with Administrator/Executive Director Kortnie Spitznogle and Resident Care Director Marta Tapia and explained the reason for the visit. During the visit LPA conducted a brief physical plant tour at 12:53 p.m., interviewed staff starting at 1:20 p.m., interviewed residents starting at 2:25 p.m., reviewed records at 3:58 p.m. and noted further investigation was required. Investigator Patterson conducted interviews with R1’s representative on 10/21/2020, at approximately 4:16 p.m. and on 11/09/2020, at approximately 3:33 p.m.; with the Long Term Care Ombudsman (LTCO) on 11/11/2020, at approximately 2:17 p.m.; with TLC Hospice on 12/10/2020, at approximately 4:42 p.m.; with facility staff on 12/14/2020, from approximately 2:35 p.m. to 3:48 p.m.; and with Facility Administrator Sara Gutierrez on 12/17/2020, at approximately 9:10 a.m. Additionally, Investigator Patterson obtained and reviewed copies of facility records, hospice records and photographs of wounds/pressure injuries related to R1. Information gathered reflected R1 was admitted to the facility on 06/01/2020. At that time R1 was ambulatory and able to articulate their needs in spite of having had a stroke and showing signs and symptoms of dementia. R1’s medical history included depression, frequent urinary tract infections, heart disease, stroke, and dysphagia. The narrative charting record for R1 indicated on 07/25/2020, R1 was found by a caregiver sitting on the floor in the middle of their living room. R1 was noted to becoming weaker and in need of total assistance with toileting and feeding. On 08/02/2020, R1’s Doctor was contacted to obtain authorization for (continued on page 3; 9099-C) (continued from page 2; 9099-C) medical assistance as R1 “seemed a lot weaker” and in need of “a lot” more assistance. On 08/15/2020, R1’s representative came and bandaged R1’s legs due to R1’s itching and scratching, which caused bleeding. Band-aids were placed on R1’s arms; however, R1 took them off twice and R1’s representative was notified. R1’s representative was not informed by facility staff until approximately 08/15/2020, that R1 had not been ambulating on R1’s own in over a few weeks. On 08/20/2020, R1 was assessed and admitted to TLC Hospice Care due to Alzheimer’s disease and rapid decline in health. During the hospice assessment, R1 was observed to have a large stage 1 area to the coccyx with multiple scabs, and stage 2 areas within; large skin tear to left lower leg; and multiple open sores to both forearms. The assessment also noted that since being admitted to the facility, R1 had rapidly declined, required support with all activities of daily living, and was in severe discomfort and significant pain. Information gathered further revealed that it was not until the hospice care was initiated that R1’s pressure injuries and wounds were diagnosed, treated and reported to R1’s representative. On the allegation: Neglect/Lack of Supervision: Resident #1 (R1) sustained multiple pressure injuries while in care. The Residential Care Director stated she was never made aware that R1 had a pressure injury or scattered skin tears until R1 was accepted into hospice care. She admitted that the facility staff’s lack of documentation and communication, but also failing to provide appropriate supervision and care, attributed to neglecting R1’s change of condition and pressure injury/wound care needs going unmet. Based on records reviewed, interviews conducted, and photographic evidence of R1’s wounds/pressure injuries, neglect/lack of supervision and care was found to have attributed to R1 sustaining pressure injuries which went unreported and not cared for, therefore, the allegation is deemed Substantiated at this time. On the allegation: Neglect/Lack of Supervision: Facility staff did not seek medical attention for Resident #1 (R1). On 08/20/2020, during the hospice care intake R1 was discovered to have pressure injuries to coccyx area and scattered wounds to arms and legs. It was further reported R1 was in significant pain. Investigator Patterson conducted interviews with the facility staff who reported that the facility does not assess or treat (continued on page 4; 9099-C) (continued from page 3; 9099-C) pressure injuries/wounds other than basic first aid; further pain medication, PRN (as needed) is not provided unless the resident asks for them. Information obtained during witness interviews found that R1 was in severe pain and believed the facility did not provide care, pain medication or did not seek out appropriate medical attention. The Resident Care Director stated once hospice care was implemented for R1, it was not the facility’s responsibility to care for R1’s wounds. She further stated she was never made aware by facility staff that R1 was in pain or had pressure injuries or multiple skin tears which continued to exacerbate while in care. She admitted the facility’s failure to communicate attributed to failing to seek out medical attention. Based on witness statements and documents obtain and reviewed, the allegation is deemed Substantiated at this time. On the allegation: Staff mismanaging resident's medication: On 12/17/2020, Investigator Lorraine Patterson interviewed administrator Sara Gutierrez who indicated if a resident appears to be in pain but cannot verbalize their need for PRN pain medication, the medication technician should contact the resident's physician for approval to provide the PRN pain medication. R1 had acute pain due to pressure injuries and multiple skin tears. According to witnesses, R1 was in obvious pain. R1's PRN pain medication was delivered to the facility on 08/21/2020. Records show R1 was prescribed two PRN narcotic pain medications which were administered on 08/24,25,27,28,29/2020. According to administrator Sara Gutierrez there was no evidence the facility staff attempted to contact anyone (physician or hospice) over the weekend of 08/22-23/2020 for approval to administer the prescribed PRN pain medications. In addition, a medication technician interviewed by the Investigator confirmed the discovery that R1 went without this pain medication for an entire weekend. Based on the administrator's statement to the Investigator and documentation showing the medication was not administered, the allegation is deemed Substantiated at this time. On the allegation: Staff not responding to resident’s call button in a timely manner. On 12/17/2020, Investigator Lorraine Patterson requested copies of the call button service alerts for R1 from facility administrator Sara Gutierrez, however these logs were never provided to the Investigator. On 11/4/2021, LPA (continued on page 5; 9099-C) (continued from page 4; 9099-C) Camara requested call button service alert records for the facility from June 2020 through September 2020. LPA was provided logs from 06/04/2020 - 09/27/2020. Upon closer review, LPA noted records were missing from 06/23/2020 through 09/18/2020. During LPA's visit on 03/18/2022, call button records were requested for the month of August 2020. LPA was provided 537 pages of records. There was only one call noted from R1 which occurred on 08/24/2020 at 1:36 p.m.; it was announced to caregivers eight times before someone responded and it took 39 minutes for the caregivers to respond. LPA reviewed the other alert records provided by the facility and noted there were numerous alerts for other residents to which staff never responded or where response times ranged from 28 - 44 minutes. In addition, based on witnesses' accounts who had visited R1 multiple times in August of 2020, staff would not respond when R1's call button was pushed and the visitors would have to locate staff by calling the main phone number. On 08/24/2020 a caregiver brought a new call button to R1 as it seemed the one R1 had was not working. Based on witness statements, this allegation is deemed Substantiated at this time. On the allegation: Resident was left in soiled diaper for extended period of time: On 08/24/2020 a witness observed R1 was sitting for an extended period in a soiled diaper (soaked in urine, urine leaked out of diaper, and the diaper was smeared with feces). The witness also pointed out R1's call button seemed inoperable. The caregiver brought a new call button and told the witness to speak with the next caregiver coming on shift about any other concerns. Other witnesses interviewed had observed R1 was left in soiled diapers for extended periods as well as feces under R1's fingernails. Based on witness statements, this allegation is deemed Substantiated at this time. On the allegation: Staff not providing adequate food service to resident: LPA Camara interviewed residents and staff on 11/04/2021. During the COVID-19 outbreaks at the facility all residents were served meals in their room due to isolation protocols set forth by the Department of Public Health. During that time period the facility lost nearly all of their cooks. Other facility staff, including management, helped with cooking while the facility searched to hire new cooks. They offered menu items suggested by their corporate office, they were taught how to make the menu items and they offered alternative menu items. However, residents who were (continued on page 6; 9099-C) (continued from page 5; 9099-C) interviewed indicated there was a short period of time when all they received were sandwiches. In addition, residents indicated that some of the food they received was cold when it should have been hot. One caregiver indicated that was a possibility depending on where the resident's room was located as they may have been served last. Based on interviews with staff and residents, this allegation is deemed Substantiated at this time. On the allegation: Staff did not safeguard personal belongings: Based on witness interviews by Investigator Lorraine Patterson, one witness discovered on 08/24/2020 R1's personal care supplies, which had been left in R1's room, were missing. The witness reported the missing items to administrator Sara Gutierrez who told the witness things should not be left in residents' rooms because things go missing. The witness was told by a medication technician that caregivers tend take such supplies for use on other residents. In addition, R1's family left an electronic item for R1 which was also missing. Based on witness statements, this allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Business Office Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.