According to the Sherman Oaks Hospital medical records, R1 was seen in the Emergency Department on 03/28/2024 at 8:20pm due to being more confused than R1’s baseline (history of confusion). R1 was awake, alert and denied being in any pain. R1 did not have any chest pain or shortness of breath and R1 denied fever or chills. R1 did not have abdominal pain, nausea, vomiting or diarrhea. R1 informed hospital staff that they felt cold. A physical exam revealed R1 was well developed and in no apparent distress. A urinalysis was done and showed no signs of infection, but some blood was seen. A chest x-ray revealed patchy air space opacites in both lungs which was noted as compatible with multifocal pneumonia. R1’s EKG was noted as abnormal. Lab work indicated R1 had slight leukocytosis, was anemic with low sodium, and was noted as having some acute renal failure. R1 was also noted as having encephalopathy and was admitted 03/29/2024 to the hospital for the pneumonia with a temperature of 98.4. R1 was not noted as having malnutrition at the time of hospital admission. During the hospital stay, R1 tested positive for MRSA and R1’s health declined. R1 was noted with worsening acute kidney injury leading to multiple organ failure and R1 passed away on 04/13/2024.

A review of the Unusual Injury/Incident report, dated 03/26/2024, documented that on 03/25/2024, at approximately 4:45pm, while returning from an outing with R1’s resident representative, both R1 and R1’s resident representative stumbled and fell as they were walking up the stairs to the facility. The administrator immediately assessed R1 and R1’s resident representative. There were no injuries noted for R1. On 03/27/2024, an x-ray was ordered for R1’s right leg, right foot, right elbow, left hand, and right pelvic region. The results revealed no fractures and listed the diagnosis as pain and swelling.

Report will continue on LIC9099-C 4th page.

A review of R2’s file revealed that R2 was admitted to the facility on 11/25/2023. A review of R2’s physician’s report, dated 11/09/2023, indicated R2’s primary diagnoses was listed as base of left femur fracture s/p surgery. The report indicated R2 had dementia, had a history of skin condition or breakdown with history of surgical wound, was able to follow instructions as well as communicate needs, R2 could leave the facility unassisted, dress and eat on their own, was able to transfer to and from bed independently and was identified as ambulatory.

A review of the Unusual Injury/Incident report, dated 03/29/2024, documented that on 03/28/2024, 9-1-1 Paramedics were contacted due to R2 exhibiting some confusion. R2 was transported to Sherman Oaks Hospital and the nature of the treatment was unknown at the time. There were no injuries noted for R1. A review of the Unusual Injury/Incident report, dated 04/09/2024, documented that on 04/07/2024, non-emergency transportation was arranged for R2 to get them to Sherman Oaks Hospital due to complaints of bodily pain.

On the allegation “Staff did not meet resident’s needs” Information obtained from file reviewed conducted revealed R2 did present UTI infections and rashes, however R2 was being seen and treated by home health, and their physician. Staff interviews also revealed that R2 was not seen by the facilities LVN because R2’s daughter, doctor and home health were heavily overseeing R2’s health. In addition all resident's interviewed revealed that their needs are met by staff. The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued