complaint·December 7, 2023

The complaint alleges that there was an incident that occurred during the overnight shift from 03/21/2022 to 03/22/2022 involving Resident #1 (R1). It was alleged that R1 had called for assistance using their pendant and staff was not responding to the requests. R1 then called 9-1-1 to request assistance. Staff #1 (S1) did respond at some point, entered R1's room and assisted R1 to their bedside commode. When emergency personnel arrived at the facility S1 was in R1's room and S1 indicated they were caring for R1, so emergency personnel left the facility. S1 then left R1 on the commode and exited R1's room. R1 continued to press their pendant, but no one responded. R1 could not find their telephone to call for assistance. R1 then self-transferred back to their bed. Documents reviewed included resident's care plan and physician's report, incident report submitted by the facility Administrator, as well as statements provided by morning staff who had found R1. Interviews and documents reviewed revealed that R1's phone was found on the bedside table with the batteries removed, although typically R1 sleeps with their phone in their bed. Additionally, interviews revealed that due to R1's condition it is highly unlikely that R1 would physically be able to remove the batteries from their phone. R1 is unsure who removed the batteries from their phone, but indicated R1 did not do it themselves. S1 did indicate they had access to R1's phone when in their room to assist. Staff interviews revealed that in the morning, R1 was found in their bed with their head at the foot of the bed and feet by their pillows with their bedding tangled. Staff stated R1 was in a "urine-soaked bed" with the chuck pad soaked through, and the sheets and mattress wet with urine. Management did interview S1 in relation to the incident, but S1's statements "did not add up." As a result of the incident, S1's employment was terminated. Staff indicated 45 calls using their pendant were not responded to. R1's resident assessment does reflect that R1 requires one person physical assistance with transfers. Interviews revealed that although R1 wore an incontinence brief, it was typical that R1 would call for assistance during the overnight shift to request transfer assistance to and from the commode. Therefore, based on interview and record review, the allegations that " Licensee did not provide safe, comfortable accommodations for resident in care," " Facility staff did not assist resident with basic care needs," " Facility staff neglected resident," and " Facility staff did not respond timely to resident's request for assistance" are deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. Today’s reports and appeal rights were reviewed and provided via email.