Del Cerro Manor III

Type of visit: Case Management - Incident

LPA Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Marta Stone. LPA then met with Supervisor Elda Acosta, who arrived later during the visit. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/22/2023). According to the LIC624: during the afternoon of 05/19/2023, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. [These medications were instead prescribed to Resident #2 (R2)]. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding that they were safe, alert, and smiling. LPA also interviewed relevant staff and reviewed pertinent facility and hospital care records. Due to their baseline memory loss, R1 was not able to participate as a reliable historian about the incident. R1’s fellow house mates also had baseline memory loss and could not remember the incident. Per their latest LIC602 Physician’s Report (dated 01/31/2023), R1 was diagnosed with Dementia and required staff assistance with storing and taking their prescribed medications. Staff interview and care records showed: During the 05/19/2023 incident, Staff #2 (S2) was responsible for giving R1 and R2 their respective afternoon medications. Instead of handing R2’s medications directly to R2 and observing them ingest them, S2 instead placed the medications in a labeled cup, then placed the cup on a meal tray. S1 subsequently picked up this meal tray and delivered it to R1 (instead of R2). [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] S1 did not read and verify the name on the cup before handing the tray, with the medicines, to R1. R1 then ingested multiple medications which did not belong to them. S1 and S2 soon recognized the medication error. Although R1 initially did not present any adverse health symptoms, S2 timely arranged for R1 to be transported to a local hospital for observation/evaluation. After arriving at the hospital, R1 displayed drowsiness and slept more than usual. Hospital discharge paperwork showed: R1 was kept at the hospital from 05/19/2023 through 05/21/2023 following an “accidental overdose.” A hospital physician diagnosed R1 with “toxic encephalopathy” (defined by the National Institutes of Heath as “brain dysfunction caused by toxic exposure”), “sinus of bradycardia with first-degree AV [atrioventricular] block” (defined by the National Institutes of Health as a heart rhythm of “fewer than 60 beats per minute”), “hypotension” (low blood pressure), and “QT prolongation” (an extended interval between the heart contracting and relaxing). The physician attributed the above acute conditions to R1 having taken medications not prescribed to them. By time of R1’s discharge from the hospital on 05/21/2023, hospital records showed their “mental status [was] improving.” Staff interview further showed: Licensee timely notified R1’s responsible person, primary care physician, and CCLD the same day the incident occurred. Licensee verbally counseled S1 and S2 and discussed the incident with the larger direct care staff team. However, Licensee had no written record/proof of these trainings/discussions. Also, the medication errors which affected R1 on the afternoon 05/19/2023 did not prevent R2 from receiving their respective prescribed medications on that date, and R2 did not ingest any medications belonging to R1. A preponderance of evidence exists to show that during the incident in question, License’s staff gave R1 medications which were not prescribed to them. The incident caused an adverse health consequence for R1, for which they were kept at a hospital for two (2) nights. One (1) deficiency was thus cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). CCLD determined that the deficiency resulted in resident illness; an immediate civil penalty of $500.00 was thus charged and noted on the LIC421-IM. A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Acosta, to whom a copy of this report, the LIC 809-D, the LIC421-IM, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 6, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 7, 2023

87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not assist 1 of 6 residents (R1) with self-administered medications as needed/prescribed, which posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2023

Plan of correction: Per licensee, S1 resigned from facility employment around June 2023. Licensee agreed to retrain S2 and all remaining direct care staff on “The Seven Rights of Medication Administration” and licensee’s expectation that the same staff member performs the “Seven Rights” from beginning to end. By the POC due date, Licensee agreed to E-mail LPA the proposed date for the training. No later than 09/30/2023, Licensee agreed to E-mail LPA a copy of the training sign-in sheet as evidence of training completion.

Allegation investigated: Resident was hit while in care.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA Correia met with Caregiver .....to whom was explained the purpose for the visit. The Department’s investigation consisted of staff, resident, and outside source interviews. The investigation also consisted of facility and resident records review. It was alleged Resident1 (R1) was hit by a facility caregiver. A record review revealed R1 was admitted to the facility April 26, 2021, was 98 years old, non-ambulatory, and had a primary diagnosis of Syncope and Collapse, and several other secondary health conditions. Records also revealed at the time of admission R1 was recovering from a fall and was disoriented and confused due to several transfers from different hospitals and rehabilitation facilities. Unsubstantiated Interviews with an Outside Sources (OS1) revealed in July 2021 R1 was diagnosed with a UTI and during a medical appointment R1 alleged a new staff member at the facility had slapped them. OS1 reported at that time R1's file had already notated R1 was displaying behaviors of being confused and/or disoriented. Facility records and staff interviews revealed there was no new staff members at the time of the allegation, records also revealed all staff members had worked at the facility prior to R1’s admission. Staff interviews all corroborated R1 was very confused and would often carry on conversations by herself, and would tell random stories. Interviews and record reviews also revealed no known knowledge or documentation of the incident occurring, and no history of any abuse by staff towards residents is care. Resident interviews revealed no incidents of abuse by facility staff. The interviews with the residents in care all provided positive feedback regarding the staff and facility. Due to lack of corroborating evidence, the finding regarding the above allegation was established to be unsubstantiated. This finding means there is not a preponderance of evidence to prove that the alleged violation occurred. LPA Correia conducted an exit interview with Caregiver Acosta will be provided a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016) and signature on this report acknowledges receipt of the documents.the state’s words, verbatim · CDSS document, Nov 29, 2022 · control 08-AS-20210713160118

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Supervisor Elda Acosta and discussed the purpose of the visit. All staff present have a current criminal record clearance. LPA conducted a tour of the facility, both inside and outside and observed residents in care. In accordance with the Department’s Infection Control, LPA evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment. No deficiencies were cited or observed on this date. The Licensee was provided a copy of their appeal rights (LIC9058 03/22). An exit interview was conducted and a copy of this report was handed to Supervisor Elda Acosta.the state’s words, verbatim · CDSS document, Oct 10, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual inspection on 10/21/2021. LPA identified herself and was granted entry into the facility by Caregiver Yesenia Garcia LPA Correia met with Licensee Ben Barth, who arrived a short time later, identified herself and explained the purpose of the visit. LPA, accompanied by Licensee Barth conducted an overall tour of the facility inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Licensee Barth including but not limited to the following sections: Clients in Care, Staff, Visitors, Facilities without COVID-19, staff and resident Vaccination data. The facility has Plans for Infection Control, and will implement Physical Distancing as needed. LPA reviewed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, ability to quarantine or isolate if necessary and essential health and safety. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing. Visitor Vaccinations, or COVID-19 test results with in the past 72 hours, are documented for tracking purposes, and to determine visitation parameters. Face coverings are worn by staff and residents as much as possible, hand sanitizer/hand washing stations readily available; a designated visitation area if necessary; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit. An exit interview was conducted with Licensee Barth and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) will be provided via email to Licensee Barth at the conclusion of the visit. An electronic reply response confirms receipt of these documents.the state’s words, verbatim · CDSS document, Oct 21, 2021