374604062-10-28-2022-08-AS-IESA-CKR9XD-20221031234522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604062
Report Date: 10/28/2022
Date Signed: 10/28/2022 12:12:51 PM

Unsubstantiated

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
04/30/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20210430160405

FACILITY NAME:	ELMCROFT OF POINT LOMA		FACILITY NUMBER:	374604062
ADMINISTRATOR:	SHEARER, KELLIE		FACILITY TYPE:	740
ADDRESS:	3423 CHANNEL WAY		TELEPHONE:	(619) 224-7300
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92110
CAPACITY:	60	CENSUS: 45	DATE:	10/28/2022
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Executive Director Kellie Shearer		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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-Staff over-medicated resident, causing their decline/death.
-Staff did meet resident’s needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by and identified himself to Receptionist Laura Cano. LPA then met with and discussed the purpose of the visit with Executive Director Kellie Shearer.

It was firstly alleged that licensee’s staff over-medicated Resident #1 (R1) with two as-needed drugs, Morphine (which it was alleged R1 was allergic to) and Lorazepam, causing R1’s health decline/death. It was secondly alleged that facility staff did meet R1’s needs because: a) R1 was placed in a memory-care facility despite having no dementia, and b) staff did provide R1 needed help to eat or drink, leading R1 to become “emaciated.” CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of relevant facility staff, hospital staff, and outside sources. Facility records, hospital records, a coroner’s report, and other outside records were also reviewed. [CONTINUED ON LIC 9099-C, 1 of 3]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 08-AS-20210430160405

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: ELMCROFT OF POINT LOMA	FACILITY NUMBER: 374604062
	VISIT DATE: 10/28/2022

NARRATIVE

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[CONTINUED FROM LIC 9099]

Facility records show R1 moved into the facility on 10-31-2019 while under the concurrent care of a new/current hospice agency. According to R1’s LIC602 Physician’s Report (completed by their new hospice physician on 10-29-2019), R1’s diagnoses included “dementia” and “myasthenia gravis.” According to R1’s LIC603A Resident Appraisal (completed by their responsible party on 10-29-2019), R1 had “confusion” and could only answer “yes/no” or “hot/cold” type questions, a notion also discussed in a March 2019 signed letter from R1’s former primary care physician. R1’s prior/former hospice agency also documented on 09-08-2019 that R1 was “unable to follow simple commands” and “unable to express [their] needs.” Per their new/current hospice agency’s Admission Certification document dated 10-30-2019, R1 was also diagnosed with “cerebral atherosclerosis” and their life expectancy was less than six months. In all the required care/medical assessment documents which Licensee collected on R1, there was no evidence either suggesting or proving that R1 was allergic to Morphine medication.

According to hospice visits notes beginning with R1’s move-in to the facility: R1 initially was on a regular-texture diet with regular thin liquids. They were still able to sit in a wheelchair but dealt with intermittent pain and nausea/vomiting. By 11-05-2019, R1 was having “episodes of dysphagia” (difficulty swallowing), so their hospice physician switched them to a “pureed” texture diet with “nectar thick liquids.” By 11-27-2019, R1 was less alert, spent all day in bed, had episodes of respiratory congestion/distress and lethargy, and now relied on continuous supplemental oxygen via a nasal cannula. By 12-11-2019, R1 had ongoing labored breathing and was too weak to transfer to the shower, switching to bed baths exclusively. On 12-13-2019, the hospice physician discontinued all routine oral medications due to R1’s inability to swallow even crushed medications. On 12-20-2019, a hospice nurse wrote of R1’s new condition: “inability to swallow food and liquids,” “suctioning” of respiratory congestion, and “[signs and symptoms] of end-of-life transitioning.” From 12-22-2019 through their death on 12-23-2019, R1 was completely unresponsive to voice and touch.

[CONTINUED ON LIC 9099-C, 2 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20210430160405

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: ELMCROFT OF POINT LOMA	FACILITY NUMBER: 374604062
	VISIT DATE: 10/28/2022

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 3]

Licensee kept electronic checklists of R1’s meal attendance: Between 10-31-2019 and 11-25-2019, R1 consistently received breakfast and lunch in the dining room, missing only two days. R1 often declined dinner. As R1’s abilities became impaired, Licensee timely updated their Service/Care Plan to capture R1’s new “dysphagia,” “pureed diet due to inability to swallow,” and inability to “tolerate transfer to a wheelchair.” From 11-27-2019 onward, caregivers consistently charted they provided tray service to R1’s room, with “tableside assistance,” for all meals. An electronic note from one facility caregiver referenced multiple coworkers by name who helped R1 eat. It also mentioned a visitor/friend helped R1 eat applesauce. In a separate visit note, a hospice nurse wrote that after R1 could no longer swallow, facility caregivers were providing “oral care multiple times per day” using hospice-provided sponge sticks that were moistened. The sponge sticks were also described in Licensee’s updated Service/Care Plan for R1.

Per R1’s physician-prescribed Medication List, their available as-needed (PRN) medicines included: a) a Morphine Sulfate 15 mg tablet by mouth, up to once every 2 hours. Half of this tablet (i.e. 7.5 mg) could be given for “moderate” pain or shortness of breath, while a full tablet (i.e. 15 mg) could be given for “severe” pain or shortness of breath; and b) a Lorazepam 0.5 mg tablet by mouth, up to once every 4 hours, for “anxiety/agitation.” Facility staff were pre-authorized to give these medicines based on R1’s needs/symptoms. Licensee maintained a Medication Administrator Record (MAR) documenting every medication dose given to R1 during their 54-day stay at the facility. Per the MAR, R1 received one half tablet (i.e. 7.5 mg) of Morphine Sulfate on 10-31-2019, 11-04-2019, 11-11-2019, 11-25-2019, 12-07-2019, 12-08-2019, 12-14-2019, 12-18-2019, 12-21-2019, 12-22-2019, 12-23-2019. R1 received a second half tablet only on 12-08-2019 and 12-23-2019. On 12-04-2019, R1 did not receive any half tablets, but instead took one full tablet (15 mgs).
The evidence shows that on 42 of 54 days, R1 received no Morphine Sulfate PRN whatsoever. Of the 12 days it was given, 11 days involved using only the smallest dose allowed by R1’s med list (i.e. 7.5 mg) at a time, and for 9 of those days, only one such dose was given. According to the Mayo Clinic’s online article titled “Morphine (Oral Route)” (updated on 09-01-2022), an adult dealing with “moderate to severe pain” would typically take “15 to 30 milligrams [of Morphine in oral tablet form]…every 4 hours as needed.” In practice, there was not a single day at the facility during which R1’s total daily Morphine Sulfate intake went past 15 mgs. [CONTINUED ON LIC 9099-C, 3 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 08-AS-20210430160405

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: ELMCROFT OF POINT LOMA	FACILITY NUMBER: 374604062
	VISIT DATE: 10/28/2022

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 2 of 3] The 3 days which R1 did receive a total 15 mgs of Morphine Sulfate were all in December 2019, during which (per hospice visits notes) R1 was on continuous supplemental oxygen for breathing difficulty. Per the MAR, R1 received just one dose of the Lorazepam PRN on 12-14-2019. It was the only Lorazepam they received during their 54 days at the facility. According to a hospice visit note from the prior day, R1 dealt with some “respiratory distress.” Per physician orders, the Lorazepam PRN was pre-authorized to help R1 during periods of "anxiety/agitation." Every Morphine Sufate and Lorazepam PRN dose which R1 received was complaint with R1’s physician’s orders.

Incidentally, per facility and hospital records, R1 was examined at the UCSD Medical Center emergency room (ER) on 11-26-2019 for “weakness.” Laboratory tests were conducted. The ER physician concluded, “Impression: Depressed level of consciousness. I suspect overall clinical picture is related to underlying medical condition and this is the natural progression of it; did medical work up all of which is reassuring based on above will send patient back to facility. There has not been any sudden change but a slow progression…” According to R1’s death certificate from the San Diego County Office of Vital Records, R1 died on 12-23-2019 from “cardiopulmonary arrest” related to their underlying “cerebral atherosclerosis,” with “myasthenia gravis” as another significant condition. The San Diego County Medical Examiner’s Office also performed an autopsy on R1’s remains, concluding that while R1 was “markedly underweight” at time of death, “Toxicological testing detected morphine in the peripheral blood (1.12 mg/L), consistent with morphine given in hospice care. Based on the autopsy findings, circumstance surrounding the death and review of provided medical records, the cause of death for [R1] is most likely related to the slow progression of multiple comorbidities…” The coroner’s report briefly discussed the physical limitations of the autopsy based on natural decay of the body, but also noted, “There was no evidence of an allergic reaction…”

Based on interviews and record reviews, a preponderance of evidence does not exist to prove that facility staff over-medicated R1 with PRNs, or that these medicines themselves drove R1’s decline in health or subsequent death. The preponderance of evidence shows facility staff helped R1 with eating/drinking/oral care needs, but R1 experienced pronounced and worsening dysphagia towards the end of their life that severely limited their intake of food/water. Both allegations are therefore unsubstantiated. An exit interview was conducted with Shearer, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC9099 (FAS) - (06/04)

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