Complaint Investigation Report

requesting copies of hospital records for C1. On 4/6/23, LPA received PIH Health Good Samaritan Hospital hospital records for C1. On 05/16/23, LPA collected copies of Staff and Client Rosters. LPA additionally conducted a tour of facility which included observations of common areas, dining room, living room, and three (3) bathrooms.

The investigation revealed the following: Regarding allegations of Resident's hygiene needs are not being met and Resident was soiled in feces for a long period of tim e , allegedly C1 was covered in dirt, bed bugs and feces and was incontinent for multiple days, the client's room was unkempt and client was also not able to care for themselves. Interviews with Administrator and facility staff revealed that C1 was not covered in bed bugs dirt or feces. They stated that C1's FM would visit the client regularly and ensured that C1 had everything that they needed and was provided adequate care. Administrator and staff denied that C1 was incontinent for multiple days and they stated that if C1 had feces on their clothing it was most likely only from that day (04/18/22). They stated that C1 was able to take care of themselves, was independent and did not require any assistance with Activities of Daily Living (ADLs). LPA review of C1's PIH Health Good Samaritan Hospital medical records revealed that C1 was hospitalized on 4/18/22 and was minimally responsive when they arrived to the hospital emergency room, and C1's clothing were noted to have been tossed due to having feces and bed bugs. C1 was also noted to have lice. C1 received treatment for lice and the clothing was thrown out by hospital staff. C1 also received other medical treatments. C1 was not interviewed as they passed away on 4/19/22. LPA conducted initial complaint visit on 4/28/22 and observed live bed bugs in two client rooms, LPA cited and issued civil penalties to the facility on 4/28/22 for observation of bed bugs. LPA's observations of three other client rooms revealed that client's rooms were not unkempt at the time of the visit. LPA review of C1's facility file documents revealed that C1 was not incontinent and did not require assistance with their ADLs, but although C1 was not incontinent, and was able to maintain hygiene care, the administrator, and facility staff failed to observe the changes in C1's health and hygiene as they had deteriorated, as hospital records stated that C1's clothing had feces, client had lice and bed bugs on their body at the time they were transported and admitted to the hospital emergency room . Hospital records also indicated that C1 was also minimally responsive when they arrived to the hospital.

Based on interviews conducted with facility staff, and LPA review of medical records, the preponderance of evidence standard has been met, therefore the above stated allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview was conducted with Tompi Sihamu. A copy of the report and appeal rights were provided to facility staff.