Complaint·October 30, 2024

Pg.2 Staff is not providing adequate care and supervision to resident. On the allegation that Staff is not providing adequate care and supervision to resident; it is the concern of the Reporting Party (RP) that the resident (R1) was not being monitored by staff and allowed R1 to self-harm by allowing R1 to self injure their fingers. To investigate the allegation LPA Elsie Campos interviewed staff, and administrator on 07/05/2023. The staff’s (S1) interview revealed that R1 came back from the hospital with bite marks to their fingers, however, the bites were covered with bandages. Furthermore, S1 stated that they were attending to R1’s biting injuries by changing the bandages and keeping the wounds clean two times a day, every day. S1 stated that they called the home health nurse on June 20 th , 2023, to inform them that they had noticed that R1 had continued to self-bite their fingers. Staff’s (S2) interview revealed that after R1 came back from hospital on 06/18/2023, R1 came back with signs of biting on R1’s hands, “they didn’t look bad, so we covered R1’s palms for prevention, but then R1 started biting their fingers. We informed R1’s responsible party, and the nurse about the concern when R1 came back from the hospital. We (staff) were monitoring R1 throughout the day and night to prevent any further self-harm. The Administrator’s interview revealed that R1 returned from the hospital after the 06/15/2023 fall with home health services. The Administrator added that staff reported right away to the Administrator when they noticed that R1 started biting their hand and fingers; furthermore, the administrator contacted R1’s responsible party and the home health nurse to inform them of the hand/finger biting. On 10/22/2024, LPA Urena spoke with the RP and interviewed them on the phone. The RP stated that when they were changing the dressings on the right hand of R1, they noticed additional self-inflicted injuries to R1’s right hand fingers and hand. LPA Urena was unable to communicate with the attending home health nurse. Home Health was being provided per hospital discharge instructions for the injury to the forehead due to the fall at the facility, and an abrasion to the hand which happened at the hospital. Continues on LIC 9099C... pg.3 Pg. 3 On 10/28/2024, LPA Urena received and reviewed medical records for R1 from the attending hospital. The medical records indicate that R1 was admitted on 06/29/2023 with Diagnosis: open wounds to right hand, necrotic (dead cells/skin tissue) in appearance to the finger. Areas of necrosis in right distal 5th digit. R1 underwent debridement of right hand and right small finger amputation due to gangrene and eschar. Based on the information obtained through interviews and record review, staff was not providing adequate care and supervision to resident; consequently, staff did not notice the change of condition of R1 and allowed R1 to further self-harm an open wound. Therefore, the allegation is deemed Substantiated at this time. Resident sustained an injury from a fall at the facility. On the allegation that Resident sustained an injury from a fall at the facility; it is the concern of the Reporting Party (RP) that the resident (R1) was not being monitored by staff and R1 sustained a fall that required hospitalization. To investigate the allegation LPA Campos interviewed staff, and administrator on 07/05/2023. The interviews revealed that the first time R1 fell on 04/03/2023, it was an unwitnessed fall. Staff was conducting the morning rounds, at approximately 5:30 a.m. at which time, R1 was still in bed. The second time staff did their morning rounds at approximately 6:30 a.m. R1 was found lying on the floor, staff noticed a skin tear, staff applied first aid, contacted the administrator and the administrator contacted the responsible party for R1. R1 was taken to the hospital for evaluation. The second fall happened on 06/15/2023, while staff assisted R1 to use the commode, when R1 got up from the commode, R1 lost their balance, staff were unable to hold them up, and R1 fell to the floor. R1 was taken to the hospital for evaluation. Per the administrator’s interview, R1 came back to the facility with stitches on their forehead. Staff and administrator stated that the R1 walked slowly with the aid of a walker and sometimes needed assistance with transferring. Staff stated that they monitored and assisted R1 throughout the day. Continues on LIC 9099C...Pg. 4 Pg. 4 On 10/22/2024, at approximately 4:00 p.m., LPA Urena interviewed R1’s representative (POA). The POA stated that R1 suffers from dementia and is non-ambulatory. R1 was at risk of falling because R1 was frail, and because R1 still insisted on getting up on their own to use the commode. R1 was admitted to the facility on 01/13/2023. On 04/03/2023, R1 had their first fall, but was not witnessed by staff. Staff found R1 laying on the floor and was observed to have a skin tear on the face, consequently POA was informed of the fall and took R1 to the hospital to be checked out. POA stated that they spoke to the Administrator about getting someone to provide 1-to-1 caregiver for R1, because R1 could get up from the bed on their own if they felt that they needed to use the commode, but needed assistance and was at risking of falling. POA stated that the administrator and the POA worked out a deal for each to pay half of the cost for 1-to-1 caregiver. The 1-to-1 caregiver provided care for about five (5) to six (6) weeks, then the caregiver left. On 06/15/2023, R1 had a second fall, sustained a cut to the face and R1 complained that they could not stand up. R1 was taken to the hospital to be evaluated. Record review of the physician’s report dated 12/06/2022 indicate that R1 had diagnosis of Cognitive Disorder and was non-ambulatory. Page 2)-Under section PHYSICAL HEALTH STATUS for motor impairment: It indicated that R1 had no motor impairments. Page 4) under section CAPACITY FOR SELF-CARE: “Observation recommended for safety”. Review of the R1’s Resident Appraisal (LIC603A) states under SERVICES NEEDED: Needs special observation/night supervision (due to confusion, forgetfulness, wondering) YES . LPA Urena reviewed discharge papers from the hospital dated 06/18/2023. The discharge papers indicated a diagnosis of ‘weakness of bilateral legs, fall, and glabellar laceration (area between the eyebrows and above the nose). Based on the information gathered through interviews and record review, the information revealed that it was agreed between the administrator and the POA that R1 required a 1-to-1 caregiver due to R1’s risk of falling. Furthermore, the Physician’s report stated that “observation was recommended for safety”; and although it does not specify what type of safety, it clearly stated that “observation was recommended for safety”. R1 sustained a fall that required a two (2) day hospitalization. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.