Complaint·October 28, 2024

Pg. 2 Staff did not provide emergency personnel with resident's proper documentation. On the allegation that staff did not provide emergency personnel with resident’s proper documentation, it is the concern of the reporting party (RP) that the staff at the facility had no information regarding the resident (R1) when EMT personnel arrived to provide care for the resident and were unable to get any information regarding the resident’ medical history or contact information for R1. On 07/26/2023 LPA Campos interviewed the administrator, and the administrator stated that when EMT arrived to provide care to R1 and asked for R1’s personal information, the administrator gave the EMT personnel a copy of the Physician’s Report. Furthermore, the Administrator stated that on a previous EMT visit, the Administrator gave by mistake the original R1’s personal information, so the administrator did not have a copy. The Administrator stated that they gave the EMT, R1’s Conservator’ card and telephone number. On 10/11/2024, LPA Urena interviewed the Administrator, and the administrator stated that they did not recall why R1 was taken to the hospital, and that the protocol when EMT’s arrive to provide care, staff are to give them the residents’ personal contact information (LIC 601), the resident’s physician’s report, and centrally stored medication list, however these documents were not provided to the EMT personnel on 07/16/2023. The physician’s report obtained by LPA Urena was incomplete as it stated to see ‘attachment’ for the diagnosis, however, the attachment was not included/attached to the physician’s report. Staff interviewed stated that they could not exactly remember if the requested documents were available at the time R1 was taken to the hospital. LPA Urena was unable to interview the reporting party, and R1’s Conservator. Based on the information obtained through interviews, the staff did not provide the EMT personnel with the R1’s medical history, and medication information. Therefore, the allegation that staff did not provide emergency personnel with resident’s medical and history documentation, is deemed Substantiated at this time. Continues on LIC 9099C... Pg. 3 Staff accepted a resident into the facility requiring a higher level of care. On the allegation that staff accepted a resident into the facility requiring a higher level of care, it is the concern of the reporting party (RP) that (R1) was extremely ill and was taken to the Intensive Care Unit (ICU) on the day EMT transported R1 to the hospital. On 07/26/2023, LPA Campos interviewed the Administrator, and the administrator stated that facility staff did everything for R1: Feeding, medications, eyedrops, vitamins, bathing, incontinent care. Staff stated that they would crush the medication and would put in in R1’s food. The LPA did not receive or found doctor’s orders for medication to be crushed and put in R1's food. R1 was not receiving hospice services while residing at the facility. The Administrator stated that the first time R1 was taken to the hospital, it was due to pneumonia. Administrator did not know why R1 was taken to the hospital the second time. On 10/11/2024, LPA Urena interviewed the Administrator and the administrator stated that R1 was receiving Home Health Services, PT (physical therapy) for mobility and transferring from chair to bed and vice versa. . Per Home Health communication with Administrator, R1 was seen by nurse with weekly visits from 12/28/22- 7/16/23 totake vitals, and was seen twice a week for physical therapy from 1/18/23- 2/22/23. On 10/11/2024, LPA Urena reviewed R1’s physician’s report dated 12/26/2022, and discharge papers from Health Care Center. Diagnosis Intestinal fibrosis, dysphasia, emphysema. R1 was to be admitted to facility with 24-hour caregiver services. Per staff interviews R1 was not receiving 24-hr, or one-to-one care. Furthermore, staff stated that home health was coming to check vitals and check sugar levels of R1. Staff does not recall if R1 was receiving PT for transferring from chair to bed and bed to chair. Based on the information obtained through record review, R1 required 24-hour care, and one person assist at all times. Therefore, the allegation that staff accepted a resident into the facility requiring a higher level of care, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.