Staff interview revealed that depending on the prescription, oxygen tanks could run out in as little as 30 minutes, increasing the likelihood that the resident is left without oxygen until the tank is changed. Staff members informed that while R1's hospice agency managed the tank, OI had also been trained to switch out the tanks and had a key to turn the oxygen tanks on and off. This created a situation where three (3) entities were involved with R1's oxygen administration. Staff members informed during interview that they did not check R1's oxygen tank because only OI used them, and OI did not inform staff when the tanks went empty. Interview with facility management revealed that staff can be trained on how to switch out the tanks and turn the flow of oxygen on, but not change the level of oxygen flow.

Outside source interviews confirmed staff statements that an Outside Individual (OI) had a key to the oxygen tanks and was trained on how to switch them out. Interview with OI revealed that there were instances when OI would arrive to the facility and observe R1's oxygen tank to be either empty or attached but not turned on. A second outside source confirmed observing the oxygen tank issues for R1 and overhearing conversations when the tank had been found to be empty without staff's knowledge.

Records evidence shows that R1's continuous oxygen prescription was clear, as documented in R1's Hospice Care Plan and Medication Administration Record. Records also show that the facility, in partnership with the hospice agency, had responsibility for ensuring R1's oxygen needs remained met at all times. Records evidence, in conjunction with staff and outside source interviews, revealed that not all aspects of R1's oxygen administration were clearly identified and communicated to all parties involved. An additional complication was the Outside Individual who became a third party in the oxygen administration. This created circumstances where R1 was not receiving continuous oxygen due to the tank being empty and no one checking it. The facility was responsible for ensuring that all aspects of R1's hospice care needs were addressed in the care plan and trained to staff, per regulations.

Interview with R1 was attempted, however, R1 was not verbal and was unable to communicate due to cognition.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Chris Tharp, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Outside source interviews corroborated staff statements that doors in certain resident neighborhoods were locked due to wandering residents and that there was no consistent practice regarding locked/unlocked doors. Interviews revealed that the specific preferences between the responsible parties for the residents of the room in question were not exactly the same. This discrepancy could have caused confusion among staff and/or situations where the door was locked or unlocked outside of one of the responsible parties wishes.

During three (3) unannounced facility visits, LPA directly observed the door in question. LPA observed the door to be open and unlocked during each visit. During one visit the door was closed for a period, and LPA observed a caregiver unlock the door for a routine check and preparation for the residents in the room to be brought out for lunch. During one visit LPA observed the door in question from inside of the room while the door was locked and closed. LPA observed that the door could still be opened from the inside of the room with the locked handle, ruling out the possibility that a resident may be locked into their room without the freedom to exit.

Interviews were attempted with the residents in question, however, the residents were not verbal and were unable to communicate due to cognition.

Regarding the allegation, "Staff did not ensure resident's medication was given as prescribed", it was alleged that staff were stealing pain medication patches from Resident 1 (R1)'s body to be used for nefarious purposes. LPA interviewed five (5) staff regarding the allegation, including Medication Technicians (Med Techs) who would have been responsible for administering the patches and a staff with clinical medical training. (Continued on LIC9099-C p.3)

During interviews staff unanimously denied that they had taken a pain patch from a resident's body before the required timeframe, or observed another staff do so. Staff interviews revealed that the patches in question were notorious for falling off a resident's body before the full medication regimen due to poor adhesive. Staff informed that the likelihood of a patch coming off of R1 was high due to the condition of their skin. Staff informed that the patches that had come off of R1 were searched for but not found, noting that the patches were very small and had likely gotten intermixed with R1's clothing or bedding and then washed. Staff informed that when a patch fell off they would replace it with a pro re nata (PRN) patch, per R1's prescription. Med Techs confirmed that no patch administration had been missed, they communicated with the hospice nurse regarding the patches coming off before the required 72 hours, and reorder requests were made to maintain the PRN supply. Staff informed that R1's responsible party declined to pursue other forms of pain management for R1 that would be more guaranteed than the patches. Staff advised that once the patches were noted to come off before the 72 hours was up, additional procedures were put in place in order to ensure the patches remained on R1's body. Staff informed that a patch with stronger adhesive was used, the patches were reinforced by additional medical tape, the patches were relocated to a location where R1 could not reach or scratch them off, a request was submitted for R1 to be given bed baths instead of showers to prevent the patches from getting wet, and staff increased the intervals with which they checked to make sure the patches were still there. Management informed that an internal investigation was conducted regarding the missing patches to rule out the possibility of a staff member intentionally removing the patches from R1's body. Management informed that the investigation did not result in any evidence of an intentional removal, and no trend was found regarding the timeframes of missing patches that would have proven that a staff member was stealing them. Finally, staff interviews revealed that after the new protocols were put in place regarding the patches, no additional patches had fallen off or gone missing.

Five (5) outside sources were interviewed and did not corroborate the allegation. While outside sources expressed curiosity or concern with the number of patches that had gone missing from R1, no outside source observed a staff member remove a patch from R1 prior to the 72 hour timeframe. Three (3) of the outside sources interviewed were medical professionals familiar with the patches and R1's care plan. These outside sources denied having any concerns of a facility staff member intentionally removing a patch from R1 for nefarious reasons. The medical professionals corroborated staff statements that the patches come off easily with elderly patients and patients with dry skin. (Continued on LIC9099-C p.4)

Four (4) of five (5) outside sources and all staff interviewed confirmed that R1 had the mobility and dexterity to reach the pain patches and potentially scratch, rub off, or remove a patch themselves. The medical professionals also informed that it was not their recommendation for R1's pain to be controlled through the use of patches; the outside sources informed there were more effective ways to do so. LPA confirmed with an outside source that after the new procedures were put in place, no further patches had gone missing from R1's body.

Review of facility records showed that regular checks were being conducted by the Med Techs to confirm patch placement. Both the Medication Administration Record (MAR) and Charting Notes during the timeframe of the complaint corroborated staff statements regarding regular patch checks. Written communication was reviewed between the hospice agency and R1's responsible party regarding the patches coming off, new orders, and how to keep the patches from coming off of R1's body. The records showed that the hospice agency advised R1's responsible party against using the patches. Charting Notes during the timeframe of complaint detailed episodes of R1 becoming agitated and moving in a way that exemplified that R1 did have the mobility to reach the patch during the time period where they were being placed on R1's arm, evidencing the potential for R1 to remove the patch or accidentally rub it off.

During an unannounced facility visit LPA directly observed R1 with the patch adhered. The patch was marked with permanent marker of the date it was placed and the Med Tech who administered it.

Interview with R1 was attempted, however, R1 was not verbal and was unable to communicate due to cognition.

Regarding the allegation, "Staff did not ensure adequate supervision was provided to resident", it was alleged that staff did not check on Resident 1 (R1) frequently enough to ensure that their oxygen cannula remained in place. Staff interviews revealed that staff conducted regular checks for residents, approximately every two (2) hours. Staff informed that the checks were to confirm R1's general safety, if they needed incontinence care or changing of clothes, and an equipment check. Staff interviews revealed that certain Med Techs would personally check R1 every two (2) hours, in addition to caregivers checking R1 every 1-2 hours.

(Continued on LIC9099-C p.5)

Outside source interviews did not corroborate the allegation. Outside source interviews were mixed regarding the availability of staff and/or if they felt the facility had sufficient staffing. Outside sources did not advise of any health or safety issues observed as a result of low staffing, informing that frustration existed for families who felt inconvenienced by not being able to find caregivers timely.

Outside sources confirmed that R1 regularly removed the oxygen cannula from their nose during moments of agitation. Outside sources additionally advised observing staff checking on R1 to ensure the oxygen cannula placement. Three (3) medical personnel from outside organizations familiar with R1's care plan were interviewed. These outside sources informed that the situations where R1 removed the cannula from their nose would not produce adverse effects or result in death; the medical personnel confirmed that R1's oxygen prescription was for comfort measures only, not a life-saving intervention. Two of the medical professionals were familiar with the facility and advised no concerns regarding resident supervision, care. These outside sources informed that the staff were competent, provided appropriate care to residents, and no acts of negligence were observed.

No records were found to show an expectation that staff should have checked R1 more frequently than the standard 1-2 hour checks.

During an unannounced facility visit, LPA directly observed a staff member go into R1's room to check on them and prepare them for the next meal. LPA observed caregivers and Med Techs walking around the facility assisting residents and answering questions from family members.

Interview with R1 was attempted, however, R1 was not verbal and was unable to communicate due to cognition.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Chris Tharp, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.