Complaint·January 21, 2025

(continued from page 1, LIC9099) On 08/30/2024, from 11:49 a.m. to 12:10 p.m., LPA Camara conducted an initial complaint investigation visit regarding the above allegation. At 9:18 a.m., the LPA interviewed Staff 1 (S1). Starting at 9:39 a.m., the LPA reviewed and obtained pertinent documents. On 11/21/2024, from approximately 10:55 a.m. to 1:02 p.m., Investigator Torre conducted interviews with the facility Clinical Director, staff, and Administrator; on 12/17/2024, at approximately 4:58 p.m., with a former staff; and on 12/19/2024, at approximately 8:44 a.m., with R1’s primary Neurologist. In addition, the investigator reviewed Community Memorial Hospital medical records, Sevita NeuroRestorative Rehabilitation medical records, Hoag Hospital medical records, 911 audio call, and facility file documents related to the investigation. According to the Physician’s Report, dated 08/01/2024, R1’s primary diagnosis was listed as astrocytoma (brain cancer) and the secondary diagnosis was shunt revision (medical device to drain excess cerebrospinal fluid from the brain to the abdomen). Physical health status was noted as fair with motor impairment. R1 was noted to being confused and able to communicate occasionally indicating expressive aphasia. R1 required assistance with activities of daily living (ADLs) and instructions to the facility were to monitor head for swelling. The prescribed medication section indicated to see provided list, which was the medication review report. The medication review report revealed the prescribed medication included the following: Lacosamide Oral Tablet 100 MG – one tablet by mouth two times a day for seizure disorder. Levetiracetam Oral Tablet 750 MG – two tablets by mouth two times a day for seizure disorder. R1’s service plan indicated R1 needed medication administration and/or treatment assistance required on a regular basis, including PRN medication. A review of the Sevita NeuroRestorative Rehabilitation medical records revealed that R1’s past medical history included brain cancer with astrocytoma, asthma, hyperlipidemia, history of seizures and status post multiple VP shunt revisions done by the Neurosurgical team at Hoag Hospital. On 08/03/2024, at 3:00 p.m., R1 was discharged from Sevita NeuroRestorative Rehabilitation to the Lexington Assisted Living facility. (continued to page 3, LIC9099-C) (continued from page 2, LIC9099-C) A review of the facility Medication Assistance Records (MARs) for R1 revealed nine prescribed medications. R1 was administered the seizure medication Levetiracetam Oral Tablet 750 MG two tablets, twice a day which began on 08/04/2024. The record revealed a blank entry on 08/11/2024. The record also did not list R1’s other prescribed seizure medication Lacosamide Oral Tablet 100 MG – one tablet by mouth two times a day. Furthermore, a review of the missed medication report revealed on 08/11/2024, the following medication was not administered to R1 – Levetiracetam 750 MG – two tablets by mouth; Megestrol Acetate 20 MG – one tablet by mouth; and Acetazolamide 250 MG – one tablet by mouth. In addition, the Centrally Stored Medication and Destruction Record and Facility Active Medication Report revealed only one seizure medication was documented. The review of the Unusual Incident Report revealed on 08/13/2024 at approximately 11:00 a.m., R1 was found in bed shaking uncontrollably by staff. Staff called 911 and R1 was transported to Community Memorial Hospital. According to the medical records, R1 was admitted to the hospital for tonic-clonic seizure due to not being given the right dosages of seizure medication. R1 was diagnosed with acute respiratory failure, metabolic encephalopathy, on mechanically assisted ventilation, seizure, shock, and hydrocephalus. The secondary diagnosis included anxiety with depression, hypertension, limited code, physical debility, glioblastoma, and metabolic acidosis. R1 was intubated and sedated. On 08/15/2024, R1 was transferred to Hoag Hospital for further evaluation and management. Based on the Department’s investigation, the medical records revealed R1 was prescribed two seizure medications that were administered at the rehabilitation facility R1 was admitted to prior to R1’s discharge to the facility. The facility records revealed the Medication Assistance Records (MARs) did not capture one of the prescribed seizure medications (Lacosamide 100MG) which was on the medication list attached to the Physician’s Report. Furthermore, review of the facility MARs revealed the seizure medication (Lacosamide 100MG) was not listed on R1’s medication list or ever administered to R1. The interview of the facility Clinical Director revealed the facility did not compare the medication bottles R1 arrived with at admission with the (continued on page 4, LIC9099-C) (continued from page 3, LIC9099-C) medication list provided on the Physician’s Report. The review of the 911 audio call revealed the caller stated R1 was observed “experiencing a seizure” before becoming unresponsive. The interview of R1’s primary Neurosurgeon revealed that both seizure medications were equally important and the failure to administer one of the two would result in a seizure. Thus, the missed dosages of R1’s seizure medication during the 10-day stay at the facility, more than likely caused the seizure. Therefore, the allegation “Neglect/Lack of Care and Supervision – Resident #1 (R1) required medical attention due to staff’s failure to dispense prescribed medication while in care of the facility” is deemed Substantiated at this time. A $1,000 immediate civil penalty is assessed today due to licensee was cited for the same deficiency within a 12-month period (87465(a)(4) on 08/22/2024). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued. (continued from LIC9099A, page 1) On 08/30/2024, from 11:49 a.m. to 12:10 p.m., LPA Camara conducted an initial complaint investigation visit regarding the above allegations. At 9:18 a.m., the LPA interviewed Staff 1 (S1). Starting at 9:39 a.m., the LPA reviewed and obtained pertinent documents. On 11/21/2024, from approximately 10:55 a.m. to 1:02 p.m., Investigator Torre conducted interviews with the facility Clinical Director, staff, and Administrator; on 12/17/2024, at approximately 4:58 p.m., with a former staff; and on 12/19/2024, at approximately 8:44 a.m., with R1’s primary Neurologist. In addition, the investigator reviewed Community Memorial Hospital medical records, Sevita NeuroRestorative Rehabilitation medical records, Hoag Hospital medical records, 911 audio call, County of Orange certificate of death, and facility file documents related to the investigation. According to the Physician’s Report, dated 08/01/2024, R1’s primary diagnosis was listed as astrocytoma (brain tumor) and the secondary diagnosis was shunt revision (medical device to drain excess cerebrospinal fluid from the brain to the abdomen). Physical health status was noted as fair with motor impairment. R1 was noted to being confused and able to communicate occasionally indicating expressive aphasia. R1 required assistance with activities of daily living (ADLs) and instructions to the facility were to monitor head for swelling. The prescribed medication section indicated to see provided list, which was the medication review report. The medication review report revealed the prescribed medication included the following: Lacosamide Oral Tablet 100 MG – one tablet by mouth two times a day for seizure disorder. Levetiracetam Oral Tablet 750 MG – two tablets by mouth two times a day for seizure disorder. R1’s service plan indicated R1 needed medication administration and/or treatment assistance required on a regular basis, including PRN medication. A review of the Sevita NeuroRestorative Rehabilitation medical records revealed that R1’s past medical history included brain cancer with astrocytoma, asthma, hyperlipidemia, history of seizures and status post multiple VP shunt revisions done by the Neurosurgical team at Hoag Hospital. On 08/03/2024, at 3:00 p.m., R1 was discharged from Sevita NeuroRestorative Rehabilitation to the Lexington Assisted Living facility. (continued on LIC9099C, page 3) (continued from LIC9099C, page 2) The review of the Unusual Incident Report revealed on 08/13/2024 at approximately 11:00 a.m., R1 was found in bed shaking uncontrollably by staff. Staff called 911 and R1 was transported to Community Memorial Hospital. According to the medical records, R1 was admitted to the hospital for tonic-clonic seizure due to not being given the right dosages of seizure medication. R1 was diagnosed with acute respiratory failure, metabolic encephalopathy, on mechanically assisted ventilation, seizure, shock, and hydrocephalus. The secondary diagnosis included anxiety with depression, hypertension, limited code, physical debility, glioblastoma, and metabolic acidosis. R1 was intubated and sedated. On 08/15/2024, R1 was stable to be transferred to Hoag Hospital for further evaluation and management. A review of the Hoag Hospital medical records revealed R1 presented to the hospital from Ventura Community Hospital on 08/16/2024, at approximately 2:30 p.m., complicated by respiratory failure with suspicion from aspiration pneumonia. R1 was intubated following a witnessed seizure. The records noted R1 was last hospitalized in July 2024 with sepsis due to cellulitis of the skull with wound dehiscence of surgical site. In addition, R1 had a history of astrocytoma status post multiple surgical resections and now with VP shunt followed by Neurologist Dr. Duma. Due to unlikelihood of R1 making any meaningful progress, R1’s resident representatives opted for comfort focused care. On 08/18/2024, R1 was extubated, and NG tube was removed. R1 remained on IV seizure medications. R1 expired at the hospital on 08/20/2024, at 3:38 p.m. The cause of death was pulmonary arrest within minutes, aspiration pneumonia (no choking) within days, and end stage astrocytoma within months. Multiple surgical tumor resections since 2023 and seizure disorder were noted. Based on the Department’s investigation, the medical records revealed R1’s medical history included astrocytoma (brain tumor) diagnosed in 2016 with recurrence, history of hydrocephalus (water in the brain) status post VP shunt placement in November 2023, and recent (07/01/2024) VP shunt revision. The interview of R1’s primary Neurosurgeon, Dr. Duma revealed he did not contribute R1’s death to the missed medication and subsequent seizure. Dr. Duma stated R1’s death was inevitable due to R1’s extensive medical history and medical condition (“very bad, large brain tumor”). Therefore, the allegation “Questionable Death – Resident #1 (R1) sustained multiple seizures and subsequently expired due to staff’s neglect” is deemed Unsubstantiated at this time. (continued on LIC9099C, page 4) (continued from LIC9099C, page 3) During a visit to the facility on 1/16/2025, LPA Camara conducted a brief tour of the memory care unit starting at 3:35 p.m. and toured several rooms which all appeared clean and tidy. LPA interviewed two staff at 3:40 p.m. and 3:43 p.m. who both worked at the facility during R1's stay at the facility. Both staff recalled R1, both staff recalled R1 had some incontinence care needs, however neither staff ever recalled seeing R1's room left unkempt or R1's shower chair being left soiled. One staff indicated sometimes during showers residents will have bowel movements during the shower which requires extra cleaning. The staff will clean it during the shower, however it requires scrubbing after the shower is completed. That staff did not recall seeing R1's chair left dirty. Based on the observations of the rooms in the memory care unit and interviews with staff, the allegation R1's room was left unkempt is deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report issued.