Burlingame Senior Home

Allegation investigated: Staff leave residents unattended for an extended period of time.

On 8/2/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220609140245. LPA met with the administrator and explained the purpose to today's visit. Regarding allegation of staff leave residents unattended for an extended period of time, during the investigation, the reported party stated that resident #1 (R1) is being assisted to bed after dinner and there was no staff at the facility to provide care until the next morning. During the investigation, LPA interviewed R1 who stated that upon admission, he/she was provided a bell to be utilized when he/she was in bed and R1 stated that there were staff at night to assist when needed. LPA observed a silver metal bell placed next to R1's bed. LPA interviewed resident #2 (R2) and resident #3 (R3) and both of them stated that there were staff at night and they used their call light for assistance when needed, Unsubstantiated LPA interviewed the administrator who stated that there were staff providing care and supervision all day and night. LPA reviewed the LIC 500 (Personnel Report) and it revealed 24 hour staffing coverage. In addition, LPA interviewed Staff #1 (S1) and Staff #2 (S2) and both of them stated that they worked on the night shift several times a week. They also reported that they sleep during the night and get up to provide assistance when residents rang their call bell. S1 reported sleeping in a room behind the kitchen and S2 reported sleeping on the couch in the living that is shared with the residents. This is a deficiency and will be cited on LIC 809 under Personal Accommodations and Services as the facility did not provide comfortable living accommodations and privacy for the residents and staff. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is discussed with the administrator. A copy is provided. Regarding to staff did not provide residents with walker, the reporting party stated that the facility staff took away resident #1 (R1)'s walker after they assisted R1 back to bed. As part of the investigation, LPA interviewed R1 who stated that the walker was placed by the head of the bed when she is bed. However, R1 also reported not being able to reach for the walker as it was blocked by the quarter bed rails at the head of the bed, the removable metal device placed by the foot of the bed and the dresser in between the head and the foot bed rails. LPA reviewed the medical documents provided by the facility, there was no physician's order and/or notes concerning the above devices. Based on this investigation, this complaint allegation is determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis as R1 and staff reported that the walker was placed next to the bed. However, the additional observation concerning the devices that facility placed next to R1's bed will be cited on a LIC809 under Postural Support. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Aug 2, 2022 · control 14-AS-20220609140245

Type of visit: Case Management - Other

On 8/2/2022, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220609140245. LPA met with the administrator and explained the purpose of the visit. During the course of the investigation, the allegation of staff leave residents unattended for extended period of time was deemed to be unsubstantiated. However, Staff #2 reported sleeping on the couch in the resident's living. Based on the complaint investigation, the facility did not ensure to provide a comfortable living accommodations and privacy for residents and staff. This deficiency will be cited on LIC809D. During the course of the investigation, the allegation of staff did not provide residents with walker was deemed unfounded. However, LPA observed resident #1 (R1)'s bed has two quarter bed rails installed by head of the bed and R1 reported facility staff placed another removable metal device by the foot of the bed and a dresser in middle space between the head and the foot of the bed. Facility staff acknowledged the above devices were placed next to R1's bed and reported the intent was to prevent R1 from falling out of the bed. According to the documents provided, there was no physician's order for any of the devices used above and administrator acknowledged that R1 used the quarter bed rails for reposition while in bed. However, there was no physician's order. Based on the complaint investigation, the facility did not obtain a physician's order and/or documentation for using the devices mentioned above and these devices were restricting R1's movement. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator. A copy of this report and the Appeal Rights are provided.the state’s words, verbatim · CDSS document, Aug 2, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(1) · Plan of correction due date: Aug 4, 2022

87608- Postural Support..(a) Based on the individual's preadmission appraisal,..(1) Postural supports shall be.. to improve a resident's mobility and independent functioning..but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement is not met as evidenced by the facilty places devices next to resident #1's bed without a phsyician's order and staff reported the intent was to prevent resident #1 from falling out of bed which posed an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: The facility will reassess the devices that are currently being used and will obtain a physician's order for the devices that will be continued to use after the assessement, and provide documentation. The facility will remove the device(s) immediately that is not prescribed by the physician, The administrator will review this regulation and provide a copy of a signed acknowledgement statement after the review. In addition, the administrator will provide in-services to staff and provide a copy of the sign-in sheet by 8/4/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Aug 15, 2022

87608 Postural Supports..(a) Based on the individual's preadmission appraisal,.(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record This requirement is not met as evidenced by the facility did not obtain a written order from the physician for resident #1's quarter bed rails which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: The administrator will provide in-services to staff and provide a copy of the sign-in sheet to CCL by the plan of correction due date 8/15/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a) · Plan of correction due date: Aug 15, 2022

87307 Personal Accommodations and Services..(a)Living accommodations and grounds..The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, .... This requirement is not met as evidence by Staff #2 reported sleeping in the resident's living room at night which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: The administrator will rearrange a sleeping accommodation for staff #2. Administrator will review the regulation, provide an in-service to staff and provide a copy of the in-service sign-in record to CCL by the plan of correction due date 8/15/2022.