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13 | On 10/13/2020, the Department (CCLD) concluded a complaint investigation received on 2/5/2020. Licensing Program Analyst (LPA) Calzada arrived unannounced and met with Lacy Berry, Administrator/Director, and explained purpose of inspection. LPA was wearing a N95 mask during inspection and was screened per Covid-19 precautionary measures upon entering the facility.
During the investigation, the Department interviewed the facility Director, multiple staff and residents and reviewed documentation including, but not limited to, residents (R1) physician’s report, care plan, facility incident reports, hospital and skilled nursing medical records, and other records. The results of the investigation are as follows:
Allegation: Resident was hospitalized due to dehydration due to staff negligence.
Hospital medical records indicated that resident had colon cancer. Facility incident report notes that resident went to the emergency room on 11/8/2019 for slight swelling in hands and feet and for experiencing weakness. Resident's plan for care at the hospital dated 11/8/2019 included IV hydration. Ombudsman stated resident was adamant about not receiving water and resident’s family member indicated that resident stated that the water provided at the facility was not in her reach. The certificate of death for resident lists "dehydration" as a significant condition that contributed to death on 12/18/2019, but not resulting in the underlying cause. Multiple staff interviews indicated that resident would drink water and coffee daily and juice and chicken broth occasionally too.
**cont on 9099C(1)..
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| Substantiated | Estimated Days of Completion: |
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32 | (9099C(2))The certificate of death for resident lists "malnutrition" as a significant condition that contributed to death. Intake notes from skilled nursing, dated 11/13/2019, indicate that resident had several medical conditions, including protein calorie malnutrition. Staff stated that resident was a "picky eater" and would eat between 10-50% of their meals, for several weeks, becoming worse for the last 3-4 weeks. One staff stated that resident looked malnourished and was skinny and bony. Staff also stated that resident was able to choose what they ate and snacks were provided to resident throughout the day and included chips, goldfish crackers and ice-cream. Resident’s Individual Service Plan (ISP), dated 8/6/2019, notes that staff needs to “supervise and provide encouragement to resident during meals” and “offer healthy snacks” due to resident being “at risk for nutritional compromise and dehydration due to poor oral intake”. Staff interviews revealed that staff were not supervising resident during their meals but would only occasionally check on them during their meals.
Based on information obtained, the department finds the above allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following two (2) deficiencies are being issued. Failure to comply with the Plan of Corrections by the noted due date may result in a penalty being assessed.
An immediate civil penalty in the amount of $500.00 is to be assessed for resident sustaining a serious bodily injury while in care. As a result of the serious bodily injury which contributed to death, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.
Exit interview. Copy of report and appeal rights provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
10/27/2020
Section Cited
CCR
87466 | 1
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7 | 87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: | 1
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7 | Licensee/Administrator agree to conduct staff training and create logs to document when observations and/or changes in conditions are made.
Documentation of training agenda and attendees faxed to CCLD by 10/27/20. |
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14 | Based on record review, the facility did not follow resident's care plan and “monitor for signs/symptoms of dehydration”, as noted in resident's care plan, dated 8/6/2019, and seek timely medical attention, which resulted in the resident going to the emergency room on 11/8/2019 and having a diagnosis of “failure to thrive”, which posed an immediate health and safety risk to resident in care. | 8
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Request Denied
Type A
10/27/2020
Section Cited
CCR
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7 | 87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by:
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7 | Licensee/Administrator agree to also include in training any new changes of condition so all staff is aware and provide care accordingly.
Documentation of training agenda and attendees faxed to CCLD by 10/27/20. |
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14 | Based on interviews conducted, the facility did not follow resident’s care plan, dated 8/6/2019, that staff "supervise and provide encouragement during meals" that were delivered to resident’s room, which posed an immediate health and safety risk to resident in care and resulted in resident going to the emergency room on 11/8/2019 and being diagnosed with "failure to thrive". | 8
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14 | **Repeat Violation within last 12 months** |
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13 | During the course of the investigation, LPA interviewed, Administrator, Dietary Supervisor and (6) med-tech and caregiver staff. LPA reviewed documentation including, but not limited to, staffing schedules, resident shower schedules and shower refusal documentation. In addition, documents specific to resident (R1) were reviewed, including physician’s report, care plan, care notes, and physician notifications. The results of the investigation are as follows:
Allegation: Facility is not adequately staffed to meet the needs of resident(s) in care.
Interviews with the Administrator and (6) med-tech/caregiver staff revealed that most staff feel that current staffing levels are sufficient. One staff stated “In the past, we were short on staff as people quit, but then we rehired and it's good currently”. Another staff stated that “at the time resident lived here, there were three to four caregivers in the "am" but we would only have two caregivers on the "pm" shift and another staff member stated “we always have enough on the “am” shift”. Two staff stated that there is still insufficient staffing on the ‘pm” shift. Interviews revealed that although it is more difficult to give all scheduled showers when there are only two caregivers scheduled in a shift, showers are still being given and are rarely missed since “a new system was set up where the med-techs help cover the floor so the caregivers can shower residents.” And one staff stated “staff will talk to each other more to coordinate which caregiver will give their shower first and if we are short staffed now, the resident is showered the next day”.
*cont on 9099C(1).. *
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32 | (9099C(1))...Review of resident’s care record for May- Oct 2019, shows that resident refused a shower once in May, September and October, twice in August, three times in June and five times in July. Interviews conveyed that staff feels that residents’ needs are being met with only one staff stating “I am concerned about the residents”. LPA reviewed staffing schedules from April- June 2020, which show three or more caregivers were scheduled on all “am” shifts in April and most “am” shifts in May and in June and at least two caregivers were scheduled during “pm” shifts from April- June, with the majority of the days having three caregivers scheduled. Night shift from April -June shows two or more caregivers were scheduled. Administrator stated the goal is to have three caregivers on the “am” shift, which is busier than the “pm” where there are two caregivers scheduled and there are also two med-techs on each shift. Review of shower schedules show that 2-4 showers are scheduled daily in each hall with the majority of the days having 3 showers scheduled. Shower refusal documentation shows that there were 4 residents in April and 2 residents in May who refused showers. Interviews revealed that the only time showers are not given is if a resident refuses. Resident lived at facility until November 2019. Staffing and shower schedules were reviewed in Dec 2019 and staffing levels were found to be insufficient due to showers being missed, and a citation was issued at that time.
Based on conflicting information obtained from interviews and shower documentation reviewed, LPA finds the allegation to be UNSUBSTANTIATED.
Allegation: Resident was left soiled for an extended period of time. Resident’s pre-appraisal assessment, dated 4/19, notes that resident is continent and independent with toileting. Interviews indicated that resident was not incontinent until towards the end of residing at the facility, on/around October, 2019 and would regularly use the commode.
**cont on 9099C (2) .. |