Complaint·February 21, 2024

On 05/18/2023, at approximately 2:35 p.m., Investigator Patterson conducted an interview with R1’s resident representative; on 07/10/2023, from approximately 11:45 a.m. to 1:15 p.m., with the interim Executive Director, staff and residents; on 07/11/2023, at approximately 1:16 p.m., with the Ventura County Medical Examiner Coroner’s office Investigator; on July 13, 2023, from approximately 9:04 a.m. to 5:41 p.m., with staff; and on 07/20/2023, from approximately 2:43 p.m. to 3:52 p.m., with the interim Executive Director and staff. Additionally, Investigator Patterson reviewed Los Robles Hospital Medical Center records, County of Ventura Medical Examiner’s Office Investigative Report #1170-22, death certificate, photos, and facility file documents related to R1. Facility records reviewed revealed that since 09/07/2021, R1 stayed at the facility at different times on a temporary short-term respite basis. The Physician Report dated 07/22/2022, listed R1’s primary diagnosis as hypertension, hyperthyroid, BPH, and peripheral vascular disease. The secondary diagnosis was listed as Coronary Artery Disease (CAD), cataracts, osteoarthritis, a fall history, and previous head injury. R1 is ambulatory and independently transfers. R1 follows directions and communicates their needs. R1 has the capacity for self-care and medication management. The facility Assessment /Level of Care dated 07/18/2022, documented R1 is an early riser and receives two weeks of respite care. R1 has limited vision and no dietary restrictions, R1 is independent, and bed status is out of bed all day. R1 requires no status checks or assistance with Activities of Daily Living (ADL). R1 walks with a walker and requires grab bars in the bathroom. R1 bathes and performs ADLs and transfers independently. The facility reported no history of falls, and R1 does not require special care. A review of the facility concierge shift notes for 07/31/22, between 8:00 a.m. and 4:30 p.m., summarized that R1’s resident representative called the facility between breakfast and lunch. R1’s resident representative reported R1 is not answering their phone. The caregivers were paged to check on R1. It was further documented, "We only have two caregivers on the floor!!" "They were tending to other residents," and that a caregiver was sent to R1’s room but there was no answer. "We saw R1 at breakfast but not lunch," and that a caregiver was sent again, knocked and there was no answer, and that the caregiver did not have a key, so the facility had to get a caregiver with a key. At 2:00 p.m., the caregiver went to R1’s room to check on R1 because R1’s resident representative was very concerned that R1 was not answering their phone. The investigation further revealed that R1’s resident representative reported that on the morning and afternoon of 07/31/2022, they alerted the facility’s receptionist on at least two (2) occasions that they were concerned that they could not reach R1. (continue to LIC9099c) Photos of screen shots of R1’s cell phone showed that R1’s resident representative had attempted to call R1 at 7:27 a.m., 10:01 a.m., 10:39 a.m., and 12:24 p.m. R1 was not checked on until R1 was found in their room at approximately 2:15 p.m., unresponsive with a head injury. Los Robles Regional Medical center records reflected that on 07/31/2022 at 3:00 p.m., R1 was transported to the hospital via ambulance. Medical records further noted that the R1 was found down with obvious signs of trauma. Staff found R1 in the afternoon covered in feces, urine, and blood. R1 was not responsive, left pupil was larger than the right, abrasions over all four extremities. Moreover, Computed Tomography (CT) scan of the head reported a large left subdural hematoma measuring up to at least 2.1 cm with associated 1 cm of left to right midline shift. Large hematoma in the left frontal region measuring at least 3 cm, moderate bilateral subarachnoid hemorrhage with large amounts of blood. R1 was not intubated due to R1s DNR status. Due to the extensive hemorrhage, trauma surgeon determined that no surgical intervention. R1 was admitted in critical condition and was unstable for transfer. R1 was subsequently placed on comfort measures and passed away on 08/03/2022. The certificate of death revealed the cause of death was intracranial hemorrhage. Based on the interviews conducted and records obtained during the course of the investigation, the Department determined that there is sufficient evidence to support the allegation of “Neglect/Lack of Care and Supervision: The facility failed to respond to resident in a timely manner” and “Questionable Death due to a lack of neglect and lack of supervision”. Therefore, the allegations are deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. Administrator were informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.