Complaint·March 6, 2023

CONT - PAGE 2 Regarding the allegation: Staff failed to provide timely medical attention It was alleged that staff failed to obtain timely medical attention for R1. Records review revealed that R1 was admitted to the facility on 07/05/2022 with hospice services, with the admitting diagnosis of metastatic cancer, hypertension, and dementia. Prior to admission to the facility, R1 was hospitalized and was diagnosed with lung cancer that had metastasized to the bone. Medical records indicated that R1 had multiple malignant masses throughout R1’s right lung, one of which that had progressively increased in size. As a result, R1’s appraisal dated 07/10/2022 noted that R1 was in ‘constant pain’ due to the masses. The investigation revealed that R1 suffered an unwitnessed fall in the facility courtyard on 11/05/2022. The staff whom assisted R1 after R1’s fall claimed that R1 was checked for immediate injuries and then placed back in their wheelchair. Staff mentioned that R1 sustained a cut on their forehead and mentioned that R1’s forehead hurt. Another staff whom assisted R1 indicated that R1 complained of hip pain. Staff reported that they informed the House Manager via phone and left a handwritten note, indicating that R1 had fallen. Interviews with the House Manager confirmed that staff had called them the evening of 11/05/2022 and reported R1’s fall; yet, the House Manager admitted that they notified the hospice agency and R1’s responsible party of R1’s fall the next morning, 11/06/2022. Staff indicated that they had assumed that R1 was ‘ok’ and did not require immediate medical attention. A hospice nurse assessed R1 on 11/06/2022. Interviews with the hospice nurse revealed that R1’s vitals and heart was checked. Although the nurse claimed that they checked R1’s range of motion, additional witnesses stated that R1 had complained of hip pain during the assessment. The information obtained from the hospice nurse supported claims that they recalled R1 expressing pain; however, they did not recall where the pain was located. The LPA also reviewed facility charting notes regarding R1. It was documented on 11/06/2022 that R1 ‘had some swelling on [R1’s] left temple area and scrape… no visible injuries on [R1’s] body but appears to have pain on [R1’s] left side, left shoulder particularly.’ Staff interviews and R1’s appraisal dated 07/10/2022 stated that R1 was ‘always’ in pain due to R1’s tumor. R1’s responsible party indicated that R1’s cancer was in their chest and had spread to their lungs. Yet, records review and interview revealed that R1’s hip pain was unrelated to R1’s cancer diagnosis. Records and interviews confirmed that R1 suffered another unwitnessed fall in R1’s room on either 11/06/2022 or on 11/07/2022 at approximately 4:00 a.m. CONT - PAGE 3 R1 was placed back into bed. Staff claimed R1 was ‘crying in pain’ when R1 lifted their arms and chose to contact hospice. Whereas hospice wanted to send a nurse, staff indicated that R1’s responsible party wanted R1 to be sent to the hospital. On 11/07/2022, R1’s responsible party took R1 to the hospital. Upon admission to the hospital, it was discovered that R1 sustained a left hip fracture. R1 did not return to the facility. Based on the investigation, there is sufficient evidence to support claims that the facility failed to provide timely medical attention for R1. R1 suffered two unwitnessed falls and complained of pain. Facility staff felt they fulfilled their due diligence by contacting the hospice agency regarding R1’s fall. As directed per regulation, the facility is expected to notify R1’s hospice agency instead of calling 9-1-1 if R1 was experiencing an emergency that was directly related to the expected course of R1’s terminal illness. R1 was receiving hospice services due to their terminal diagnosis of cancer and dementia. R1 fell on two occasions and was experiencing hip pain. This pain was not directly related to the reason as to why R1 was admitted to hospice. The allegation, ‘staff failed to provide timely medical attention’ was Substantiated at this time. Regarding the allegation: Lack of supervision resulted in R1 sustaining a fracture It was alleged that staff failed to supervise R1, which resulted in R1 falling and sustaining a fracture. Records review revealed that R1 was admitted to the facility on 07/05/2022 with hospice services, with the admitting diagnosis of metastatic cancer, hypertension, and dementia. R1’s physician’s report dated 7/7/2022 stated that R1 had an unsteady gait, had auditory and visual impairment, needed assistance to transfer to and from bed, exhibited confusion and wandering behavior, and required assistance with all aspects of care besides feeding oneself. Staff claimed that R1 ambulated with a wheelchair and stated they would have to remind R1 to utilize their wheelchair when ambulating through the facility. Staff stated that R1 would oftentimes get out of their wheelchair and use it as a walker. Medical records dated 07/01/2022 indicated that prior to R1 being admitted to the facility, R1 was deemed a fall risk due to R1’s mental status and condition. R1 suffered an un-witnessed fall in the facility courtyard on 11/05/2022. Staff interviews stated that R1 would regularly sit out on the courtyard after dinner. Staff claimed when they put R1 out on the courtyard, they told R1 ‘not to get up’ and said they left R1 alone because there were cameras in the courtyard. CONT - PAGE 4 A review of facility camera footage confirmed that at approximately 4:48 p.m. on 11/05/2022, R1 was observed sitting in their wheelchair in the courtyard .R1 was observed to be alone, and the footage did not capture staff ‘making rounds’ or checking in on R1. The camera footage skips to 5:48 p.m., where R1 is seen laying on their side in the courtyard, shoes scattered above their head, and two caregivers were lifting R1 up into the wheelchair. As the camera footage jumps from the time stamp of 4:48 p.m. to 5:48 p.m., one is unable to determine the time in which R1 fell, or the time that staff found R1 on the ground. Records and interviews confirmed that R1 suffered another un-witnessed fall in R1’s room on either 11/06/2022 or on 11/07/2022 at approximately 4:00 a.m. R1 was placed back into bed. Per the interviews conducted, there was no indication that staff implemented any fall precautions to decrease the likelihood of R1 suffering a fall at the facility. Although the Administrator claimed that R1 had a pendant and call button to ask for assistance, the investigation revealed that R1 did not wear a pendant while residing at the facility. There was no additional evidence to confirm whether R1 had a fall mat, bed alarm, or other fall prevention measures in place. Whereas the Administrator indicated that the facility did not provide 1:1 care, information obtained from other staff interviews revealed that staff believed that R1 either required 24-hour supervision, or 1:1 care. Whereas R1’s hospice nurse did not deny R1’s need for 1:1 care, it was communicated that R1 did not ‘necessarily need’ 1:1 care. R1’s family member also indicated that R1 required 1:1 care but knew R1 was not receiving 1:1 care when R1 resided at the facility. Based on the information obtained in interviews, observations, and records review, there is sufficient evidence to support the claim that due to lack of supervision, R1 suffered a fall and subsequently sustained a fracture. Staff stated they left R1 in the courtyard alone because there were ‘cameras in the courtyard’. Multiple staff stated that R1 either required 1:1 care or 24-hour care. Lastly, the facility did not implement fall preventative measures to lessen the likelihood of R1 sustaining a fall. This allegation is deemed Substantiated at this time. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. A copy of the report was issued, along with appeal rights.