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32 | On 1/11/21, night shift caregiver, S1 told the department’s investigator that on the day of the incident 11/23/20, she last saw R1 at approximately 6:30 AM and that R1 “looked normal” lying in their bed. Other staff reported that a dayshift caregiver, S2, found R1 at approximately 0800 hours on 11/23/20. From the laundry room, S2 observed R1 alone in the restroom with their arms and head inside the laundry room through the laundry chute. S2 then summoned assistance from S3, at which time S3 called 911 reporting R1 was found in the bathroom with no pulse and not breathing. The Resident Care Coordinator (RCC), who had been alerted by S2, removed R1 from the laundry chute, without requesting others’ assistance, resulting in R1 sustaining additional injuries after they were already unresponsive, not breathing and were observed by RCC to have greying skin and lips.
First responders arrived on scene and began lifesaving procedures until a DNR (Do not resuscitate) was produced by facility staff. Chico Police Department was dispatched to the facility regarding a death report. Chico Police Officer spoke with facility staff to include the RCC, The RCC provided a statement indicating R1 was located with “an arm sticking out of the laundry cute” and “laid” R1 on the floor at which time an “injury” occurred. RCC later stated to Butte County Sheriff’s office the laceration was not there prior to the incident.
Butte County Sheriff’s Office Deputy was dispatched to the facility for a coroner’s report. Time of death was determined to be 9:07AM. Deputy later received a call from S2 stating what was reported to Chico Police regarding R1’s body placement wasn’t accurate and was coerced into making false statement by the RCC. S2 stated RCC felt night shift was at fault for not checking on R1 and did not want the facility to get in trouble.
CDSS received the complaint and during interviews with staff it was revealed staff did not follow the care plan put into place for the safety of the resident. RCC stated R1 was able to toilet themselves. When asked if the facility could have prevented the incident, RCC responded “R1 got into the situation” and “I never really thought a resident would put their self through that.” RCC later admitted that R1 wasn’t located with only one arm through the chute but was located in the laundry chute stuck with both arms and upper torso in the chute.
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32 | The investigation’s review of R1’s care plan revealed R1’s required physical assistance from staff with toileting. Staff were instructed to physically take the resident to the restroom (even on night shift) every two hours during waking hours and every three hours during sleep hours. Every morning at approximately 7 AM, staff are required to wash the resident’s face, comb hair, moisturize skin and dress the resident appropriately. Wanderer spot checks are required 11 times a day and residents sleep pattern should be monitored and annotated every morning at approximately 5 AM. Records further state that R1 was incontinent of bowel and bladder, uses a wheelchair, requires assistance with activities of daily living and at times has behaviors. R1’s care plan listed Monday (the day of the incident) as a shower day.S1 stated in an interview that R1 would drop clothes in the bathroom chute multiple times daily when R1 felt their clothes were dirty.
An autopsy of R1 revealed R1’s cause of death was from natural causes due to Atherosclerotic Cardiovascular Disease. Therefore, the investigation was unsubstantiated for the facility’s actions or inaction having lead to R1’s death. However, autopsy findings revealed significant injuries such as abrasions to the lower lip and superior parietal scalp, contusions to the superior parietal scalp and both knees, superior parietal subgaleal hemorrhage and superior parietal subarachnoid hemorrhage.
Based on interviews and review of records, the Licensee failed to provide care and supervision per the resident’s care plan, between the hours of approximately 6:30 AM and 8:00 AM on 11/23/21, resulting in the R1 gaining access to and getting stuck in a facility laundry chute. The Lack of supervision resulted in R1 having a medical emergency and suffering injuries. This allegation is substantiated.
Based on interviews and review of records S2 and the RCC, provided false statements to law enforcement. RCC also encouraged S2 to provide false statements and document misleading information about the incident and mishandling of R1 in the course of an emergency. Therefore, the allegation of inimical conduct is substantiated.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/01/2021
Section Cited
CCR
87464(f)(4) | 1
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7 | Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident …with those activities of daily living such as dressing, eating and bathing ...
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7 | ***Amended***
Licensee will submit a statement of understanding that residents are to receive assistance with needs identified in their appraisal needs and services plan . the statement will include that the licensee will submit a comprehensive plan for how the services will be provided to all current residents by 06/01/2021.
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14 | This requirement was not met as evidenced by staff interviews and resident records report R1 required assist of daily living and incontinence care which was not provided. This posed an immediate risk to the resident. | 8
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14 | ***Amended***
This statement and plan to be submitted to CCL by fax by the POC date of 06/01/2021.
An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. |
Type A
06/01/2021
Section Cited
CCR
1569.50 | 1
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7 | 1569.50 Conduct Inimical (3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California | 1
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7 | Licensee agrees to develop the importance of truthfulness, correct information, as well as including supervisory consequences for reporting in the facilities reporting and documentation policy.
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14 | This requirement is not met as evidenced by: Based on staff interviews, RCC submitted false statements to law enforcement and forcibly removed R1 from the chute. This posed an immediate risk to the resident. | 8
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14 | ***Amended***
Licensee will submit their plan for developing/training of such standards and include that training will be completed and proof submitted by 06/01/2021. Licensee will also submit documents of supervisory action taken for S2/S4 |