Complaint Investigation Report

Additionally, there was a reminder located on the kitchen refrigerator of the facility reminding staff to take R1 to brush their teeth daily and clean their fingernails as well. R1’s Physician’s report dated 4/1/2022 determines that R1 has a diagnosis of Dementia and needs assistance with basic bowel movement practices/toileting and gets resistant to bathing. Based on interviews conducted with facility staff, it was revealed that 4 out of 7 couldn’t recalled performing those task with R1 because resident gets combative so they leave them alone and come back a different time. Therefore, the facility staff did not follow their house rules, weekly staff schedule task procedures and R1’s Physician’s report about resident’s care needs. The preponderance of evidence standard has been met; therefore, the above allegation of resident’s care needs is not being met is found to be SUBSTANTIATED.

Regarding allegation of facility did not provide medical care to resident in a timely manner. Per reporting party, on 8/18/22 suspected that R1 had a fall at night instead of an episode where R1 pulled down the commode, the lamp and everything was found on the floor by the licensee. Also, on 9/8/22 R1 sustained 2 inches in diameter bed sore on tailbone and 9/30/22 R1 was observed with a rash in their legs. Based on records review, R1’s LIC602 Physician's Report dated 4/11/22 does not indicate a history of skin condition or breakdown prior to the admission to the facility. LPA obtained pictures from outside party dated 9/27/22 at 8:05pm from licensee showing R1’s leg with rash. Although, licensee confirmed that the facility notified R1’s responsible party about the diaper rash and bruising, the facility staff did not contact R1’s Physician, they just put some ointment on R1, and they recovered. Per facility’s Medication Administration Record dated 10/1/22 for R1, there was a prescribed Betamethasone Dip 0.0520 cream 456 mg to be applied topically twice per day. Based on LPA’s interviews conducted with licensee, R1 sustained the bruise on their arm because of R1 pulled out the dresser and throwing all the stuff away, then their responsible party took R1 to their Physician. Per Licensee, the facility staff does not seek for medical treatment for R1 because R1's primary physician is located in Monterey and they did not take them to the ER/hospital because it was a little rash and not a big deal. However, LPA obtained R1’s diagnosis from the UCSF dermatopathology Specialist Services dated 10/28/22 confirming that the findings are consistent with a hypersensitivity reaction to an arthropod bite or a medication. The preponderance of evidence standard has been met; therefore, the above allegation of facility did not provide medical care to resident in a timely manner is found to be SUBSTANTIATED.