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32 | Regarding the allegation that residents are not receiving services paid for: It was alleged residents were not taken out of their rooms for 3 months in 2020 but were paying additional fees to be escorted around the facility. LPA interviewed AD and facility staff who stated that care plans are created based on residents’ needs and, from these care plans, assignment sheets are created which specify what services the residents are to receive and at what frequency. All services are presumed provided unless the care staff reports that the resident refused the service. Refusals are documented in the resident’s progress notes and the facility will address the issue with the resident and their family. LPA interviewed 10 residents and none of these residents corroborated this allegation.
Regarding the allegation that lack of care and supervision resulted in a resident's death: Per witness statements, on 05/26/20 Resident #3 (R3) had a pulse oxygen reading of about 95%. R3’s pulse oxygen was not read again until 05/28/20 when R3 called for assistance with complaints of nausea and vomiting at which point their pulse oxygen was checked again and read at 82%. R3 was taken to the hospital where they passed away on 06/01/20. Per staff statements, R3’s primary diagnosis was hypertension with congestive heart failure, R3 was not on hospice, R3’s passing came as a surprise, and R3’s cause of death was respiratory failure related to their congestive heart failure. LPA reviewed R3’s Physician’s Report dated 03/22/18 which states R3’s diagnoses included congestive heart failure, coronary artery disease, and mild cognitive impairment. R3’s Physician’s Report also states that R3 was ambulatory, able to follow instructions, able to communicate needs, able to leave the facility unassisted, able to store and administer their own medications, and had a do-not-resuscitate order but was not on hospice. LPA reviewed Hoag Hospital Irvine Medical Records dated 09/20/23 which state on page 11 that R3 had a history of congestive heart failure, a pacemaker, recurrent pneumonias and bronchitis and that R3 was taken to the hospital on 05/28/20 due to hypoxia after facility staff tested R3’s pulse oxygen at 70%. On pages 17 and 18, the Medical Records indicate that, while having a pulse oxygen of 70%, R3 did not express any shortness of breath and was speaking clear and complete sentences. Per page 35 of the Medical Records, at the hospital R3 stated that, overall, they have been in very good health. However, assessment at the hospital revealed R3 was “profoundly hypoxic” and had “severe sepsis.” On page 47, the Medical Records describe that despite aggressive measures in the Critical Care Unit, R3’s condition deteriorated and R3 and their family decided to start comfort care in lieu of additional aggressive treatment. Per page 65 of the Medical Records, R3 passed away on 06/01/20 at the hospital. The Medical Records do not indicate that hospital staff suspected neglect or lack of care at the facility. |