It was alleged that facility staff failed to communicate R1’s change of condition in a timely manner as it related to R1’s aggression and behavioral challenges. As a result of R1’s behavioral challenges, it was alleged that the facility assisted R1 with the self-administration of medication without prior approval or against what was prescribed by hospice. Interviews conducted with a hospice representative noted that they often felt they received updates regarding R1’s progression during their regularly scheduled visits. It was at that point, per the interviews and record review of hospice nursing notes, that hospice was notified of R1’s behavioral changes. Interviews with facility nursing staff confirmed that staff may wait to provide updates to an outside agency if they knew they were visiting the facility regularly.

A review of the facility’s ‘Service Plan Conference Sheet’ dated 11/4/2021 indicated that a conversation was had regarding R1’s agitation and behaviors. As a result of that care plan meeting, a medication change was made to address R1’s agitation. Records review indicated that R1’s ‘as needed’ medication (PRN) for Seroquel was discontinued on 11/05/2021, and a routine Lorazepam (Ativan) was prescribed twice a day. The LPA reviewed hospice nursing notes from 11/08/2021. Records from the 11/08/2021 visit indicated that facility staff communicated to a hospice representative that they had called in a ‘stat delivery’ for Seroquel over the weekend due to R1’s behaviors (Saturday, 11/06/2021 or Sunday 11/07/2021). An interview with the hospice representative and hospice nursing notes revealed that hospice reminded facility staff that the Seroquel had been discontinued. The LPA reviewed the physician’s orders and confirmed that the facility had received a written order from R1's hospice to discontinue the Seroquel, and to start Lorazepam (Ativan) twice a day. The LPA reviewed R1’s electronic medication administration record (eMAR) and observed that there were no logged entries indicating that the Seroquel was administered on 11/06/2021, 11/07/2021, or 11/08/2021. However, the dates following the 11/08/2021 date were notated as ‘discontinued’.

The LPA reviewed hospice nursing notes from a 11/24/2021 visit. Records from the 11/24/2021 visit indicated that facility staff informed the hospice representative that the staff had assisted R1 with the self-administration of an additional PRN Seroquel every night prior to the 11/24 visit to R1 due to increased agitation. This allegedly was not reported to hospice nor R1’s responsible party until the hospice representative went to the facility on 11/24/2021. The LPA reviewed R1’s electronic medication administration record (eMAR) and observed that there were no entries indicating that R1 was assisted with the self-administration of PRN Seroquel from 11/17/2021 – 11/28/2021. However, the dates following the 11/28/2021 date were notated as ‘discontinued’.

Interviews revealed there had been several changes with the nursing staff during the time of R1’s stay at the facility, and hospice revealed that with the changes in staff, the nurses at the facility seemed unaware of R1’s condition or R1’s medication regimen. The LPA reviewed the facility progress notes pertaining to R1 and noted that there were no entries charted between 11/02/2021 – 12/06/2021. Progress notes did not indicate that R1’s responsible party nor the hospice agency was notified of R1’s behavioral challenges, and/or the need for additional PRN medication. However, the LPA reviewed Service Plan Conference Sheets which summarized the care plan meetings that took place regarding R1 and identified that a representative from R1’s hospice agency was present to discuss R1’s treatment plan on 11/4/2021, 11/18/2021, and 12/8/2021. A review of hospice nursing notes indicated that R1 was seen by a hospice representative at least three times a week. However, interviews with a hospice representative and a review of hospice nursing notes detailed that the facility failed to proactively communicate changes in R1’s behavior or condition, and that hospice would find out about changes in R1 when they would conduct their visits.

Based on the information obtained during the course of the investigation, there is sufficient evidence to support the claim that staff failed to notify hospice of R1’s change of condition in a timely manner. Staff felt that as hospice was regularly visiting the community to see R1, staff felt that the hospice agency was regularly notified of R1’s behavior. However, there is no supporting documentation to aid in claims that the facility was in regular communication with the hospice agency. The hospice agency felt that they found out about R1’s change of condition or behavioral challenges during their visit(s), or when staff would communicate the need for additional PRN medication as a result of R1’s behavior. This allegation is deemed Substantiated at this time.

It was alleged that staff were unable to meet R1’s needs due to the facility’s inability to manage R1’s aggressive behaviors. Prior to R1 being admitted to this facility, R1’s family felt that R1 was overmedicated in their previous placement, which caused R1 to appear overly sedated and disengaged. As such, the family felt it was in R1’s best interest to discontinue R1’s medications in order to determine an appropriate medication regimen. Records review indicated that upon admission to the facility on 10/28/2021, all of R1’s medications were discontinued, except the ‘as-needed’ (PRN) medications. Records review and interviews noted that once R1’s medications wore off, R1 began displaying aggressive behaviors. As R1’s behaviors increased, routine medications were added as an attempt to manage R1’s behaviors. Staff interviews and records review indicated that the facility had worked with hospice staff on identifying a favorable medication regimen that would assist in managing R1’s behaviors. The Service Plan Conference Sheet dated 12/8/2021 indicated a 1:1 companion was needed for R1 for additional oversight and safety monitoring, as R1’s behaviors had not improved. As such, the facility attempted multiple strategies towards decreasing R1’s agitation.

Notably, a review of hospice nursing notes indicated that on several occasions, R1 appeared to be aggressive or combative, which prohibited staff from assisting R1 with care. The following was observed via a record review of the hospice notes: on 10/29/2021, caregivers claimed they attempted to assist R1 with a shower or personal care but R1 began to punch and bite; on 11/02/2021, staff reported that they were unable to provide care to R1 due to increased aggression; on 11/03/2021, R1 allegedly refused a shower or personal care of ‘any kind’; on 12/08/2021, care staff indicated that R1 was soiled and became aggressive with any attempt to assist with personal care; on 12/09/2021, it was reported that attempts to provide personal care were met with violence from R1; on 12/11/2021, R1 became combative with care staff when assistance was provided.

Whereas staff stated that they did their due diligence to ensure that resident care needs are met, a review of hospice nursing notes indicated that on several occasions R1 appeared disheveled or unkempt. A review of hospice nursing notes revealed the following: R1 was observed partially dressed in the facility hallway on 11/15/2021 and 11/16/2021; R1 was found in another resident’s room on 11/24/2021, surrounded by several pairs of shoes; R1 was found sitting on the floor in soiled clothing on 12/04/2021,12/08/2021 and 12/09/2021.

A review of the facility’s ‘Service Plan Conference Sheet’ dated 11/4/2021 indicated that a conversation was had regarding the proposed genetic testing for medication management.

Yet based on the investigation, there is sufficient evidence to support the claim that the facility failed to meet the resident’s needs. Although facility employed multiple strategies to aid in managing R1’s increased agitation and behavioral challenges, evidence obtained in interviews and records review demonstrates that staff were unable to meet R1’s care needs on multiple occasions. The LPA reviewed the facility progress notes pertaining to R1 and noted that there were no entries charted between 11/02/2021 – 12/06/2021. As such, the LPA was unable to observe the documented efforts the facility utilized to meet R1's needs in real time. Based on the preponderance of evidence, the allegation ‘Staff did not meet resident’s needs’ is 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. A copy of the report, and appeal rights, were provided.

It was alleged that R1 was often observed in soiled clothing. Staff whom provided care to R1 confirmed that R1 had incidents where they would urinate or defecate on the floor; however, staff said that once it was observed, staff would clean R1 up and put R1 in clean clothes. Staff also noted that R1 was aggressive when staff would assist R1 with care. Yet, staff said they would either return at a later time to assist R1, would do a change of face to have another caregiver assist R1, or would request the assistance of another caregiver to provide care to R1. Staff negated claims that R1 was soiled for an extended period. In addition, staff stated that even if they had checked on R1 within fifteen minutes, R1 would still have the opportunity within that window of time to soil their pull-up or clothing due to their bowel and bladder incontinence. However, additional interviews and a review of hospice nursing notes supported claims that R1 was found in soiled clothing or in an unkempt state on 12/4/2021, 12/08/2021, and 12/09/2021. Yet, the reviewed hospice notes did not indicate the condition of the diaper, nor that it appeared that R1 had appeared soiled for an extended period of time. Based on the investigation, there is insufficient evidence to support claims that staff left R1 in soiled clothing for an extended period of time. Although the allegation may have happened or is valid, there is insufficient evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff made inappropriate comments towards resident

It was alleged that facility staff made an inappropriate comment inquiring about when R1 was going to pass away. It was alleged that the tone of the comment was insensitive and suggested that staff wanted R1 to pass quickly. Staff whom had provided oversight and care to R1 during R1’s last days at the facility denied claims that they made any inappropriate comments regarding the expected time period of R1 passing. The LPA conducted an interview with a hospice representative whom provided care to R1, and they denied knowledge of this claim. The LPA reviewed summary notes from the hospice visits and did not uncover documentation that spoke to the alleged comment. Several staff stated they overheard R1’s family members inquiring about R1’s passing and made claims that they did not want R1 to be in any pain but denied claims of hearing facility staff making any insensitive comments. Based on the information obtained from interviews and records review, there is insufficient evidence to support the claim that staff made inappropriate comments towards the resident. This allegation is deemed Unsubstantiated at this time.

It was alleged that staff observed R1 ingesting a fork. However, information obtained during the investigation did not indicate whether it was a metal or plastic fork, but it was alleged that this happened within the first four weeks of R1 being admitted to the facility. There was no information shared as to whether R1 was harmed as a result of this incident. Staff whom administered care to R1 denied knowledge of R1 ingesting a fork or any foreign object. Staff said that R1 needed assistance with all activities of daily living, including assistance with feeding. Yet staff claimed that they had not observed or overheard the claim that R1 had ingested a fork. The LPA reviewed facility progress notes for R1 and did not read notes pertaining to this incident, nor were there any unusual incident reports sent to the Department regarding this claim. Based on the information obtained from interviews and record review, there is insufficient evidence to support the claim that staff did not prevent a resident from eating a hazardous object. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff did not prevent residents from engaging in inappropriate behaviors

It was alleged that on approximately 12/16/2021, a resident wandered into R1’s room and attempted to remove the blankets off of R1’s bed. This incident allegedly took place when R1 was lying in bed, and it was determined that R1 was near the end of their life. Information obtained from interviews conducted with staff whom had provided care to R1 were unable to confirm claims that this specific incident took place. However, staff confirmed that residents are out of their room for most of the day and if they are not congregating in common spaces, some residents are ambulating through the facility. Staff admitted that residents will oftentimes enter different rooms; however, due to their dementia diagnosis, residents may be unaware that there are in the incorrect room. Staff said that they do their due diligence to redirect residents to appropriate places. A review of hospice nursing notes indicated that on several occasions, R1 was observed to be in rooms other than their assigned room. However, there was insufficient evidence via interviews or records review to corroborate claims that staff failed to prevent residents from engaging in inappropriate behaviors as it relates to residents going into R1’s room. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.