It was alleged that staff failed to provide timely medical attention to R1, as it was alleged that R1 went several days without eating or drinking before R1 was sent to the hospital. A review of facility notes indicated that staff documented on 06/05/2022 that R1 presented with little appetite. A review of electronic communication revealed that Administrator informed the home health nurse regarding R1’s status of refusing to eat and drink on 6/7/2022. Records review indicated that the Administrator again informed the home health nurse on 6/8/2022 that R1 refused to eat and drink, and the home health nurse responded that R1 may have needed to go to the hospital. An interview with the home health nurse supported claims that they had informed the Administrator that due to R1’s condition, R1 potentially needed to go to the hospital. However, records indicated that further discussion would be had with R1’s family. On 6/10/2022, a review of electronic communication indicated that the Administrator informed the home health nurse that R1’s intake of liquids and food was limited, and that R1 was declining. It was then communicated that R1 would possibly be admitted to hospice on 6/10/2022, but further investigation revealed that this did not take place.

According to Mayo Clinic, adults with severe dehydration should be treated by emergency personnel; in addition, salts and fluids delivered through a vein intravenously are absorbed quickly and speed recovery. On 6/10/2022, the home health nurse attempted to give R1 fluids intravenously yet were unsuccessful as they were unable to locate a vein. Yet, the nurse was able to draw blood from R1 that day. On 6/12/2022, R1’s primary care physician notified the Administrator that as a result of R1’s blood work, R1 needed to go to the hospital. Laboratory records indicated hypernatremia (high concentration of sodium due to water loss), kidney failure, and dehydration. Upon admission to the hospital, R1 was admitted with severe dehydration and kidney dysfunction.

Based on the investigation, R1 experienced a change of condition of limited eating and drinking, which lasted several days. The Administrator felt that as R1’s home health agency and physician were aware of R1’s condition, the facility fulfilled their responsibility of ensuring that R1 received timely medical care. However, the attempt of providing R1 fluids intravenously from the home health nurse on 06/10/2022 indicated that R1 required medical attention outside of the scope of the facility. In addition, it was confirmed that R1 was unable to receive fluids intravenously on 06/10/2022. R1 was sent to the hospital on 06/12/2022 at the request of R1’s physician; yet, the investigation demonstrated that R1 required medical attention prior to 06/12/2022. The allegation ‘Staff did not provide medical care in a timely manner’ is deemed Substantiated at this time.

It was alleged that R1 experienced a change of condition and the facility did not notify R1’s responsible party in a timely manner. Interviews with R1’s responsible party indicated that they went to the facility on 6/8/2022 and was informed by staff that R1 had consumed minimal fluids and meals since Sunday, 6/5/2022. A review of facility notes revealed that on 6/5/2022, staff documented that R1 had a lack of appetite and had refused to drink. Similar notes were documented on 6/7/2022, where staff noted that R1 refused to eat all meals and refused liquids throughout the day. Although R1’s responsible parties had visited R1 at least once a day, R1’s responsible party communicated that they had not visited the facility between 6/5/2022 – 6/7/2022.

Interviews with the Administrator revealed that the Administrator was initially notified of R1’s decreased appetite and refusal of liquids from facility staff on 6/5/2022. It was then reported that R1’s physician was notified of R1’s condition via phone on 6/6/2022. A review text messages between the Administrator and R1’s home health nurse revealed that Administrator had informed the home health nurse of R1’s refusal of meals and liquids on 6/7/2022. On 6/8/2022, the Administrator told the home health nurse via text message that R1 refused to eat and drink and noted that R1 was likely ‘very dehydrated’. The home health nurse responded on 6/8/2022 via text message that R1 may have needed to go to the hospital. On 6/10/2022, the Administrator informed the home health nurse via text message that R1 continued to consume minimal fluids and food and it was at that point that the Administrator mentioned that R1’s responsible party was contacted by a hospice agency to identify whether R1 was a candidate for hospice at that time. On 6/10/2022, R1’s home health nurse documented that their team had been in contact with R1’s responsible party regarding R1’s status. However, there was no indication that the facility staff had been in contact with R1’s responsible party.

The LPA further reviewed electronic communication between facility staff and R1’s responsible party and was unable to uncover messages to confirm that R1’s family was notified of R1’s condition prior to R1’s responsible party visiting the facility on 6/8/2022. The text messages between R1’s responsible party and the facility staff demonstrated that staff sent a message on 6/2/2022 to R1’s responsible party, indicating that R1 was eating and sent photos of R1 eating at the dining table with the other residents. The next text message between facility staff and R1’s responsible party happened on 6/8/2022, in which staff informed R1’s responsible party that R1 failed to eat breakfast that day and that a nursing visit was requested because R1 displayed the same symptoms of not eating the previous day (6/7/2022). Records indicated that R1’s responsible party had been to the facility that morning, 6/8/2022. There was no indication that R1’s responsible party was aware of R1’s failure to eat or drink liquids between 6/5/2022 – 6/7/2022.

The investigation supported claims that once R1 experienced a change of condition, the facility staff contacted R1’s physician and home health agency to identify the best course of action for R1. Yet there is insufficient evidence to support claims that the facility contacted R1’s responsible party regarding R1’s change of condition. Although it was noted that R1’s responsible party visited R1 on an almost daily basis, R1’s responsible party confirmed that they did not go to the facility between 6/5/2022 – 6/7/2022. It appears that facility staff felt that R1’s change of condition would be communicated to the family from either R1’s physician or R1’s home health agency, yet facility staff should have communicated R1’s change of condition to R1’s responsible party on 6/5/2022, when the change of condition was allegedly observed. Based on record review and interviews, the preponderance of evidence standard has been met, therefore, the above allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the CA Code of Regulations, Title 22 Regulations. Exit interview conducted. A copy of the report was issued, along with appeal rights.

It was alleged that R1 did not receive adequate care at the facility. The investigation revealed that R1’s condition was closely followed by R1’s physician and the assigned home health agency. Upon admission to the facility on 04/27/2022, R1 began receiving home health services due to a right femur fracture. Records indicated that R1 was regularly seen by representatives from a home health agency for routine care, physical therapy, and occupational therapy. It was observed that soon after admission, R1 began experiencing behavioral challenges. As a result, the facility worked with R1’s physician and home health agency in determining a medication regimen that would best manage R1’s behaviors. Interviews with the home health nurse whom administered care to R1 confirmed that they had talked at lengths with R1’s family and the facility staff regarding R1’s condition and R1’s response to the medication regimen, and felt that the facility staff had been attentive in regards to R1’s condition and care needs.

There were various statements shared regarding R1’s mood and affect while residing at the facility. Whereas R1 allegedly appeared attentive and calm in the presence of R1’s family, it was communicated that R1 would oftentimes yell and became overtly anxious if R1’s family left or if a staff person was unable to sit with R1 at all times. Regarding the medication adjustments, Staff denied claims that R1 was ‘constantly’ lethargic and the home health nurse whom provided care to R1 stated that they observed R1 on different dates, and at different times of the day after R1 had received assistance with the self-administration of medication and observed R1 to be alert and engaged.

In addition, it was alleged that R1 developed bruising due to staff neglect, yet insufficient evidence was obtained regarding the source of the bruising. Video surveillance revealed that R1 had what appeared to be discoloration on R1’s knees, legs and hands. Staff denied knowledge of the bruising on R1 and it was further communicated in interviews with outside agencies that R1 could have developed the bruising in the nursing facility they resided in prior to admission. There was no evidence to support claims that R1 had suffered a fall, nor that an incident had occurred which resulted in bruising. The LPA could not identify documentation in home health notes or facility notes regarding the bruising on R1, and the home health nurse denied claims of observing any bruising on R1, and negated claims of staff negligence that may have resulted in bruising.

Based on the investigation, there is insufficient evidence to support the claim that the staff did not provide adequate service to R1. Staff followed the direction of R1’s physician and home health agency regarding R1’s care and had acted in accordance to R1’s care plan. This allegation is Unsubstantiated at this time.

It was alleged that R1 was over-medicated. At the time the complaint was received, R1 had been moved out the facility, and the LPA was unable to conduct a medication audit. To investigate, the LPA obtained the Medication Administration Records (MARs) and medication orders for R1 from R1’s physician. A comparison of records indicated that the facility followed all medication orders that were prescribed by R1’s physician. An interview with a representative from R1’s physician’s office confirmed that R1 experienced a number of medication changes in an attempt to manage R1’s behavioral challenges. No concerns were communication from R1’s physician nor the home health agency assigned to R1’s care regarding the facility’s ability to assist R1 with the self-administration of medication. Records review and interviews confirmed that R1’s responsible party communicated concerns to R1’s home health agency that they felt that R1’s lethargic state was due to being over-medicated. Whereas there may have been times where R1 appeared lethargic due to the effect of a medication, an interview with a representative from R1’s home health agency indicated that they observed R1 on different dates, and at different times of the day after R1 had received assistance with the self-administration of medication and observed R1 to be alert and engaged. Lastly, staff supported claims that they only assisted R1 with the self-administration of medications that were prescribed by R1’s physician. Staff denied that they ever administered medication to R1 without an order, or without the specific instruction from R1's physician.

Based on the information obtained, there is insufficient evidence to support the claim that the staff were over-medicating R1. Staff followed the direction of R1’s physician and home health agency regarding R1’s care and had acted in accordance to R1’s care plan. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.