374602337-8-14-2020-08-AS-IESA-BTY44B-20200930184604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602337
Report Date: 08/14/2020
Date Signed: 08/14/2020 11:24:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2019 and conducted by Evaluator Adam Hamer

COMPLAINT CONTROL NUMBER: 08-AS-20190809151426

FACILITY NAME:	SANTA MARTHA RESIDENTIAL IV		FACILITY NUMBER:	374602337
ADMINISTRATOR:	FLORA KELLY		FACILITY TYPE:	740
ADDRESS:	6893 RADCLIFFE DR		TELEPHONE:	(858) 657-9173
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	6	CENSUS: 6	DATE:	08/14/2020
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Martha Kelly Luken, Licensee		TIME COMPLETED:	10:54 AM

ALLEGATION(S):

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Staff neglect resulted in resident being hospitalized for dehydration.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Adam Hamer and Licensing Program Manager (LPM) Denise Powell conducted an unannounced complaint investigation tele-visit
via FaceTime due to COVID-19. LPA and LPM gained access to the facility, identified themselves, spoke with Licensee Martha Kelly Luken and discussed the purpose of the visit, which was to deliver findings for the above allegation.

The Department’s investigation included, but was not limited to, interviews with staff, outside sources and residents of the facility. Facility and medical records were also obtained by the Department and reviewed for pertinent evidence.

Evidence obtained from interviews with staff and outside sources, and a review of medical records reveals that R1 was admitted to the facility in January 2018. At that time, R1 was appraised with mild symptoms of confusion and forgetfulness and needed services that included special observation/night supervision. R1 did not speak English, their condition deteriorated and was later diagnosed with dementia, and staff had difficulties communicating with them. Evidence shows that R1 was sometimes confused and unable to recognize their needs due to the dementia. It also shows that the facility knew that R1 had difficulty swallowing and was at risk for choking. R1’s care plan included them being required to be seated upright with one-on-one supervision when drinking and thick/easy placed in their drinks.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Girolami	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20190809151426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SANTA MARTHA RESIDENTIAL IV	FACILITY NUMBER: 374602337
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/11/2020 Section Cited CCR 87464	1 2 3 4 5 6 7	(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	1 2 3 4 5 6 7	The licensee agreed to obtain training through outside vendors on recognizing signs of dehydration and providing care for patients with dementia. Licensee agreed to submit the following documents to CCLD by the POC date: Certificate of completion for the Administrator and each staff by outside vendor for training.
	8 9 10 11 12 13 14	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. (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, the licensee did not meet the resident’s needs by failing to monitor R1’s intake of water, resulting in neglect as resident was dehydrated and required hospitalization. This posed an immediate health risk to one out of the six residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Girolami	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20190809151426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SANTA MARTHA RESIDENTIAL IV	FACILITY NUMBER: 374602337
	VISIT DATE: 08/14/2020

NARRATIVE

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Staff claimed during the Department’s interviews that they gave R1 nine glasses of water per day, and another staff claimed that R1 was given six full cups of water a day, neither mentioning that they followed the care plan with regard to R1 drinking fluids. Licensee claimed during Department interview that R1 was drinking a lot of fluids while under the facility’s care and supervision and did not have any significant changes in condition prior to being hospitalized. Licensee also did not mention that the facility followed the care plan with regard to drinking fluids.

Efforts were also made by the Department to interview several residents but, due to their cognitive impairment, the residents were not deemed to be credible witnesses and did not offer relevant information. R1 qualified and expressed during the Department’s interview, and on another occasion with an outside source, that they did not get enough water, always had to ask for it, and it was never just brought to them by the caregivers.

During interviews with outside sources, the Department learned that R1 was brought to the hospital on July 28, 2019 and diagnosed with hypernatremia, a condition that causes high levels of sodium in the blood and occurs in people who do not drink enough water. Since R1 was diagnosed with dementia, R1’s Primary Care Physician (PCP) indicated that R1 may not have felt thirst, which increased the chances of them consuming less water and consequently suffering from dehydration. Also, due to the dementia and language barrier, R1 had an inability to voice their need for fluids, so the facility needed to make sure that they provided water by their bedside and encouraged frequent drinking in moderate amounts. Investigation revealed that facility staff took away pictures R1 used to communicate their needs to staff and evidence supports staff failed to follow the care plan with frequent checks and did not monitor R1’s intake of water. The Department also learned from outside source professionals that they had concerns that the facility didn’t provide enough fluids to R1. A professional told facility staff prior to July 28, 2019 to get a sippy cup for R1 and provide them with more water. Another outside source who had frequent contact with R1 at the facility never saw R1 drinking water.

A medical records review revealed that the last sodium check for R1 was in December 2018 and it was in the normal range at 137. A review of hospital medical records revealed that R1 was admitted to the hospital on July 28, 2019 and was discharged August 5, 2019. Hospital medical records show R1 was diagnosed with various medical conditions, including dehydration, and their sodium level was elevated at 160, likely due to poor oral intake leading to large free water deficit.

Based on the evidence obtained from interviews and records review, the allegation that staff neglect resulted in resident being hospitalized for dehydration is found to be SUBSTANTIATED, as there is a preponderance of the evidence to prove that the allegation occurred. A citation is being issued in accordance with California Code of Regulations, Title 22, and is listed on the LIC9099D. A plan of correction was developed with the Administrator.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (LIC 9058 01/16) were emailed to Martha Kelly Luken; an email read receipt confirms receipt of these documents.

SUPERVISOR'S NAME: Tony Girolami	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020

LIC9099 (FAS) - (06/04)

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