Complaint Investigation Report

Interviews revealed that R1 was upset and worried that R1 was not going to get pain medication (Norco tablet 10-325 mg) because R1 had been discharged from Hospice on 9/18/2024 and would only have the Norco until 9/29/2024. R1’s last dosage of the Norco was on 09/29/2024 at 06:00am. Interviews also revealed that facility was aware that R1 had a history of suicide attempts. R1’s Medical records from Post Acute dated 08/01/2023 shows “Suicide Attempt” and Physician’s Report dated 7/28/2023, R1 shows “Suicidal/Self-Abuse.” Review of R1’s Appraisal/Needs and Services Plan does not show that facility, knowing R1’s history of “suicidal ideation” had a plan in place to prevent R1 from harming self. Even though R1’s Physician Report dated 7/28/2023, confirms R1 is “At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items” Staff still provided R1 with a razor without supervision and staff failed to take the razor back once R1 was done with it.

Second allegation: It was alleged that Resident had access to sharp object. During the investigation visit, LPA toured the facility and observed all sharps, such as knives, scissors, razors, etc. were locked away and made inaccessible to the residents present. Interviews revealed R1 would receive razors through Amazon that R1’s son would purchase and have delivered to the facility. Razor’s would be placed in a locked cabinet in the garage. Interviews revealed that when R1 needed a razor staff would just hand R1 a razor to use. Staff would not monitor or request the razor back; just assumed R1 would toss it out. Per R1’s Physician Report dated 7/28/2023, R1 is “At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items.”

Based on the information gathered the preponderance of evidence standard has been met, therefore, the allegations, that staff did not prevent resident from self-harming and Resident had access to sharp object are found to be Substantiated. Violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted and a copy of this report along with citation and Appeal Rights was sent to email on file.