1
2
3
4
5
6
7
8
9
10
11
12
13 | On 06/21/2024 Licensing Program Analyst, (LPA) Evelin Rios, made a subsequent complaint visit to the facility to deliver findings for the above-mentioned allegation. LPA met with Oscar Barrera and explained the purpose of the visit. Entrance interview conducted.
Regarding the allegation, resident sustained a fracture while in care, it is alleged due to improper supervision, resident#1 (R1) had a fall in the facility that caused a wrist fracture. To investigate the allegation, on the initial visit 05/09/2023 LPA interviewed the administrator Oscar Barrera, the co-administrator, Marina Barrera and two (2) out of three (3) facility staff. LPA interviewed two (2) out of (4) residents able to communicate with LPA living at the facility. On 05/09/2023 LPA also requested and reviewed facility documents, including but not limited to R1’s physician report, preplacement appraisal, resident appraisal, appraisal needs and service, and functional capabilities. On 05/18/2023 LPA conducted a telephone interview with R1’s responsible party (RP) and attempted to interview R1.
(Continued to LIC9099C) |
| Substantiated | Estimated Days of Completion: |
|
NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | (Continued from LIC9099)
On 05/14/2024 LPA conducted a subsequent visit to the facility and conducted follow up interviews with the administrator and staff employed during the initial visit. On 05/23/2024 LPA obtained R1’s subpoenaed medical records. Medical records obtained for R1 report on 04/14/2023 R1 was diagnosed with fracture of right wrist and hand and confirmed by a Radiology diagnostic on 05/11/2023 reporting an acute, intra-articular fracture of the distal radius, the fracture is healing, and the fracture line remains visible. In other words, there was a bone break, and the fracture was still mending at that time.
According to interviews, on the morning of 04/12/2023, staff noticed R1 had a right swollen wrist and was complaining about pain. Staff brought it to the administrator’s attention who then notified R1’s responsible party (RP). RP took R1 to urgent care the same day. Administrator was notified R1 would be taken to the hospital for further diagnostics as RP believed urgent care had not done enough to address R1 wrist injury. Interviews with RP revealed administrator did not have an explanation for the fracture. Administrator revealed they did not believe the wrist was fractured at the time. Staff, administrator, and co-administrator interviews deny witnessing a fall that would have caused a fracture to R1’s wrist. Interviews with residents deny witnessing or having knowledge of R1 having a fall at the facility. Interviews with staff revealed either witnessing or being told, R1 would become aggressive during the evening. On one occasion R1 scratch staff. R1 was also observed hitting themselves against walls and a door when staff would assists R1 with bathing, dressing or toileting. A staff interviewed revealed when R1 would become aggressive R1 would be placed in the hospice bed with the bed rails up and R1 would hit the rails hard with their body and arms. Interviews conducted with two (2) out of three (3) staff and co-administrator, infer that R1 could have caused injury to themselves, during an aggressive episode.
(Page 2 of 3)
|
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/24/2024
Section Cited
CCR
87705(b)(2) | 1
2
3
4
5
6
7 | (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:(2)Safety measures to address..., aggressive behavior....This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | R1 is no longer in the facility. Licensee/ Administrator will conduct an in service training reviewing with all staff facility Program: Specific Program Information for Dementia Care at: Golden Years Home. |
 | 8
9
10
11
12
13
14 | Based on interviews conducted, the facility did not take appropriate action to mitigate R1's self harm behavior when becoming aggressive. R1 was observed hitting themselves against walls, a door and their bed rail, this poses an immediate risk to residents in care. | 8
9
10
11
12
13
14 | Administrator will provide a sign in sheet of staff that participated in the training to LPA by POC Due date 06/24/2024 |
Type A
06/24/2024
Section Cited
CCR
87705(c)(4) | 1
2
3
4
5
6
7 | (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: | 1
2
3
4
5
6
7 | Administrator will submit a copy of scheduled staff meetings for the month of July to LPA by POC Due date 06/24/2024 and keep a record of future meetings held discussing dementia residents in facility records. As per facility's own Dementia Program, "We will discuss specific observations and share techniques at our regular staff meetings. Any new information will then be utilized for the care of our dementia residents." |
| 8
9
10
11
12
13
14 | Based on information obtained one morning staff was required to prepare meals provide supervision to residents with dementia and attend to all residents, the Licensee did not comply with the cited section by not scheduling enough staff to assist residents which led to R1 sustaining wrist fracture, which posed an immediate risk to residents in care. | 8
9
10
11
12
13
14 | Licensee will schedule appropriate number of staff if administrator is not providing hands on care and supervision while scheduled at the facility. Administrator attending to work in the facility office does not count as providing proper care and supervision. |