It was alleged that on 5/19/2021, timely medical attention was delayed for R1 as staff called the wrong hospice agency when R1 had episodes of vomiting. Interviews and records review revealed that on 5/19/2021 at approximately 1:00 a.m., R1 began to vomit intermittently. Staff #2 (S2) was working night shift at that time and therefore was tasked with identifying the medication to treat R1’s condition. However, S2 was unable to find the medication needed for R1’s vomiting. It was discovered that the medication needed for R1 was in the hospice comfort kit, which is separate from R1’s routine medication. S2 did not know this at the time.

During this time, S2 attempted to call R1’s hospice agency to inform them of R1’s condition. However, interviews confirmed that S2 was calling the wrong hospice agency. Interviews confirmed that the licensee posts important numbers on the wall as it was intended to be easily accessible for staff. However, it was revealed that R1’s hospice agency had changed and the name of the hospice agency that was posted on the contact sheet on the wall had not been updated. It wasn’t until R1’s family member arrived and informed S2 that they were calling the wrong hospice agency that the correct agency was contacted. Staff admitted that the numbers on the wall were not updated; rather than S2 grabbing R1’s hospice folder, S2 was mistakenly calling the wrong number. Once R1’s family member contacted the correct hospice agency, the hospice nurse arrived at approximately 3:00 a.m.

Based on the information obtained, due to S2 mistakenly calling the wrong hospice agency, there was a delay in R1 receiving timely medical attention. In addition, S2 did not know that the medication to treat R1’s vomiting was placed in the hospice comfort kit, which caused a delay in R1 receiving the necessary medication. Whereas S2’s training hours were up to date at the time of the incident, S2 was unable to locate the medications without assistance, nor did S2 know to obtain R1’s hospice folder in emergency situations. Interviews revealed that whereas many of the staff were aware of the hospice contact, S2 was unaware. Records confirmed that R1 had been with this specific hospice agency since 12/29/2020, and the incident took place in May 2021. All staff are expected to be trained and up-to-date regarding a resident’s hospice care plan, including knowledge of the resident’s primary contact person at the hospice agency.

As it pertains to the protocol surrounding the care, services, and necessary medical intervention needed for R1, the allegation ‘Staff are not properly trained’ is Substantiated at this time. In addition, allegation ‘Staff did not seek timely medical treatment for resident in care’ is Substantiated at this time.

It was alleged that R1 did not receive medication as prescribed. In addition, it was alleged that staff were unable to locate medication, which caused a delay in R1 receiving their medication timely. Interviews and records review revealed that on 5/19/2021 at approximately 1:00 a.m., R1 was experiencing episodes of vomiting. The investigation revealed that Staff #2 (S2) was working night shift at that time, however, S2 was unable to find the medication needed for R1’s vomiting. It was further discovered that the medication needed for R1 was in the hospice comfort kit. However, S2 did not know this at the time.

The investigation further revealed that on 5/19/2021 at approximately 11:00 a.m., the hospice nurse assisted R1 with the self-administration of Morphine and Lorazepam. Interviews revealed that later in the afternoon, R1 once again began to vomit. Interviews revealed inconsistent details regarding how often R1 should receive assistance with the self-administration of Morphine. Whereas staff believed R1 could receive Morphine every six hours, a review of the prescription confirmed that as of 5/19/2021, R1 had an order to receive Morphine and Lorazepam every four hours. The investigation revealed that at approximately 4:00 p.m. on 5/19/2021, the hospice nurse advised S1 to assist R1 with the self-administration of medication – specifically Morphine and Lorazepam. However, records review and interviews revealed that S1 did not assist R1 with the self-administration of medication until approximately 5:00 - 5:30 p.m., when the hospice nurse called S1 a second time to check on R1’s condition.

Based on the information obtained, there is sufficient evidence to support the claim that staff mismanaged resident’s medication. This allegation is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited.

Exit interview conducted with both Tina Santos and Administrator Michelle Maurer. A copy of the report was issued, along with appeal rights.