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32 | Continued from LIC809...
After this incident a new process called "3 step process" was initiated on 10/13/21 by the facility to verify all medication orders, document any changes and notify supervisor immediately for any discrepancies prior to giving medications to residents in care. All med-tech and facility nurses received 8 hour annual medication management training. During today's visit LPA was provided with proof of medication training for staff following medication errors conducted on 10/6/21, 10/13/21 and 10/20/2021.
Two incident reports were submitted to CCL on 10/28/21 involving resident (R3) who on 10/25/21 at approximately 4:00pm while resident was in a common area started to shake uncontrollably with foaming in their mouth, staff contacted 911 and R3 was transported to Northbay Medical Center, responsible parties were notified. R3 was diagnosed with an episode of shaking and advanced dementia. R3 returned to the facility and a hospice evaluation was scheduled. On 10/26/21 at approximately 1:40am R3 was found on floor face down after being checked 5 minutes before, bleeding and discoloration was noted on their left eye, 911 was contacted and was transported to the Hospital. Also, responsible parties were notified, R3 was discharged the same day with a diagnosis of acute head injury, advanced dementia and fall from ground level. Facility continued to frequent safety checks to R3 a fall mat was placed and bed was placed on lowest position. During today's visit LPA observed R3's bed to make sure that resident was not being restrained in any way. LPA was informed that currently R3 is receiving hospice services due to their health has been declining and observed that R3 has a bed that was provided by hospice that doesn't restrain resident.
LPA followed up on self-report incident was received on 11/1/21 along with a SOC341 alleging suspected physical abuse involving resident (R4) who on 10/29/21 at approximately 18:00 caregiver (S3) reported that while providing care to R4 became aggressive and grabbed their wrist, S1 yelled out in pain and startled resident. S1 reported the incident to a supervisor and mentioned that they had hurt their wrist earlier and was sent out to a local clinic for evaluation. R4 resides with their partner (R5) in the facility, R4 had been showing behaviors and fear of people providing services including hospice. Shortly after this incident happened, the facility received a call from R4's responsible party reporting that they received a call from R5 reporting that someone had hit R4. Facility immediately began investigation, but there were no physical signs of abuse observed by staff, R4's doctor was notified and UTI test was performed. During today's visit, LPA conducted confidential interviews with residents, reviewed records and made observations, facility conducted in-service training to all staff about Mandated Reporting and Elder Abuse on 9/28/21 and 9/30/21.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given.
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