The Department conducted an investigation which revealed that on the morning of September 7, 2017, staff 1 (S1), whom was not trained in assisting residents with the self-administration of medications, placed Resident 2’s (R2) medications on a dining room table between R1 and R2. R2 was prescribed 12 medications. The following are medications with possible adverse effects (harmful or undesirable effects) which could have contributed to R1’s sudden change in condition:

On September 7, 2017, R1 was found breathing, but unresponsive in his room. When staff, S5 and S6, tried to sit R1 up, he began vomiting and emergency response was called. According to medical reports, R1 was admitted to the hospital on September 7, 2017 at 4:41 p.m. with acute encephalopathy and presumed sepsis of unknown etiology. He was given 2 mg of Narcan, which improved his respiratory rate. Upon learning of the medication error, S3 informed the hospital on September 10, 2017. The Associate Medical Director of Palliative Medicine stated in her progress note that it appeared “the patient’s altered mental status and respiratory failure were due at least in part to the medication error (multiple drug-drug interactions with CNS and respirator depression and other potential adverse effects.” Per Mayo Clinic, sepsis is a “potentially life-threatening complication of an infection, and occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail.” R1’s family requested comfort measures only due to R1’s (Do Not Resuscitate/Do Not Intubate (DNR/DNI) order. R1 expired on September 13, 2017 at 6:07 p.m., and an autopsy was performed. According to the autopsy report dated September 21, 2017, R1’s official cause of death was acute bronchopneumonia with coronary artery atherosclerosis, nephrosclerosis, and medication toxicity.

On September 11, 2017 at approximately 1:30 p.m a case management visit was conducted and the Licensee was cited for Title 22 California Code of Regulations (22 CCR) § 87411(a) Personnel Requirements - General which states, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.”

Today, on November 9, 2021 an additional citation is issued under Health & Safety (H&S) Code §1569.69(a)(1) Employees assisting residents with self-administration of medication; training requirements which states, “Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment.”

On September 15, 2017, the licensee was informed that a civil penalty of $15,000 might be assessed based on H&S Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation resulting in a resident’s death. This is evidenced by facility staff failure to complete all required medication training prior to assisting residents with the self-administration of medications, and staff’s failure to immediately telephone 9-1-1 and inform medical professionals of the medication error which led to the hospitalization and death of R1.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Mr. Pink's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.