Complaint Investigation Report

Regarding the first allegation, there was evidence that incorrect disposal of a medication/injection needle led to an adverse, but preventable, incident. Interviews of 4 of 4 facility managers and an internal Accident/Incident Report revealed that on the morning of 06-02-2022, Staff #1 (S1) [see LIC811 Confidential Names List for a description of S1] was cleaning/wiping down a table in the facility’s dining room, when their hand was pierced by a loose needle on the table, necessitating S1 receiving basic first aid at the facility before undergoing blood testing at an off-site occupational medicine clinic contracted by the licensee. S1’s Work Status Activity Report from the health clinic listed their diagnosis as, “Exposure to body fluids by contaminated hypodermic needle stick.” Interviews of multiple direct care staff present that day (each was cross-referenced against facility’s June 2022 work schedule), further confirmed that the needle in question was a medicine/injection needle, and not a sewing needle. Regulation 87303 of the California Code of Regulations, Title 22, Division 6 requires that used medication needles to be disposed of in containers which are rigid, puncture resistant, leakproof, portable, and correctly labeled as either “biohazardous waste” or “sharps waste.” The needle which pierced S1’s hand was not disposed of in such a container, and its presence on a dining room table potentially threatened the health of residents in care. Staff interviews unanimously corroborated that facility policy/practice requires used medicine/injection needles to be discarded in a sharps-disposal container. LPA observed these purpose-made containers, made of a hard red plastic with a non-removable lid, present in the facility’s medication room during his site visits.

Regarding the second allegation, the investigation uncovered statistically significant technical problems regarding the facility’s pull cords and pendant buttons. Interviews of direct care staff and managers unanimously corroborated: a) When activated, both device types are supposed to transmit a silent signal to pager devices, indicating the name of the resident who needs help and their location, b) Every caregiver and medication technician carries a pager when on duty, and c) Every “Assisted Living” resident (i.e. someone without dementia living on either the 3rd and 4th floor) is automatically issued a pendant at time of move in, but the resident’s use of the pendant thereafter is optional. During a 06-21-2022 site visit, LPA conducted an audit/test of both device types. One-by-one, LPA activated 3 randomly selected pull cords from each of the facility’s 4 floors. LPA also tested the specific pull cord cited by the complainant in their allegation.