Cathedral Care Home

Allegation investigated: Staff not providing accurate dosage of medications to resident

On 10/20/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit, met with staff (S3) and spoke to administrator (ADM) on the phone who authorized S3 to act on her behalf and sign the reports. LPA explained the purpose of the visit with staff (ADM,S3) and delivered investigation findings. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, hospital discharge summary report, hospice care plan assessments, physicians’ orders, narrative charting, medication worksheets, death report. Continued on next page, LIC 9099-C Substantiated Allegation: Staff not providing accurate dosage of medications to resident Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s admission agreement showed R1 was first admitted at the facility on 08/21/2021. Due to a change in condition, staff sent R1 to the hospital on 08/06/23, was admitted for treatment of physical deconditioning and discharged back to the facility on 08/12/23 with hospice care. Administrator (ADM) and authorized representative (POA) agreed to implement R1’s written hospice care plan (comfort measures only) dated 08/12/23 prior to the initiation of R1’s hospice care. ADM implemented R1's hospice care plan starting 08/12/23 until 08/15/23. Review of hospice care’s physician’s order dated 08/15/23 show R1’s comfort drugs dosages were increased by the hospice care physician to manage R1’s pain and anxiety. LPA interviewed ADM who stated that she refused to implement R1’s increased comfort drug dosages on 08/16/23 because she is a hospice nurse and did not believe in the hospice physician’s assessment. POA and family had to implement hospice doctor’s orders for increased comfort drug dosages until R1 passed on 08/19/23. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff was not providing accurate dosage of medications to resident was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. S3 stated S1 was the main caregiver of R1 and was no longer employed at the facility. LPA was unable to reach S1 by phone. Review of hospice records dated 8/14/23 showed hospice nurse noted R1 had blancheable pink area to bilateral heels on feet and instructed staff to float heels to avoid potential risk of the development of pressure sore(s). Hospice nurse did not observe or report presence of any pressure injuries on R1 during visits. Review of hospice notes dated 08/12/23 thru 8/15/23 showed hospice nurses assisted staff in changing and repositioning R1 and instructed staff on the proper technique for turning and repositioning R1 every 2 hours with heels floated to avoid the risk of pressure injuries. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff was not rotating and repositioning resident resulting in pressure sore(s) and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff was not rotating and repositioning resident resulting in pressure sore(s) is unsubstantiated. Allegation: Staff left resident in soiled diapers resulting in resident sustaining redness in private area Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM, S3) who denied leaving R1 in soiled diapers for extended periods of time resulting in redness in private area. Staff stated they followed R1’s hospice care plan and changed R1’s diapers frequently. Review of R1’s hospice care records dated 08/12/23 thru 08/19/23 did not show resident sustained redness in private area while in care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff left resident in soiled diapers resulting in resident sustaining redness in private area and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff left resident in soiled diapers resulting in resident sustaining redness in private area is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 15-AS-20230817132316

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(a)(4) · Plan of correction due date: Oct 31, 2023

A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by staff not providing accurate dosage of medications to resident which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: By POC due date, administrator agreed to complete and submit to CCL proof of in-service staff re-training on hospice care of terminally ill residents in compliance with Title 22 Section 87633(a)(4).

Type of visit: Required - 1 Year

On 6/6/2022 at 10:45 AM, Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and explained the purpose of the visit with Administrator Marivic Datuin. Facility has census of 5. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 76 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational. Hot water temperature was observed to be at 112.5 degrees Fahrenheit. Continued on next page LIC 809-C LPA observed the following: · LPA observed medications accessible to residents in care. · At 10:49 AM LPA observed cleaning products (Clorox spray) under unlocked kitchen cabinet · LPA strongly recommended N95 FIT testing for all staff. (technical assistance). Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with Marivic Datuin. Exit interview conducted and a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 6, 2022