In an interview with the facility administrator, Jennifer Flores (AD), it was disclosed that there has been ongoing tension with R8's family member, F1. AD explained that F1 has been in frequent conflict with staff and hospice nurses, particularly disputing R8's medical conditions and care needs. AD indicated that F1’s behavior was a key factor in R8 being removed from hospice services, as hospice nurses reportedly found it difficult to work with F1. Specifically, F1’s objections to the care plans and medical recommendations, including the administration of seizure medication for R8, contributed to the nurses' decision to discharge R8 from their services. AD clarified that while F1 wanted R8 to be placed on hospice, the hospice nurses did not agree, as they did not consider R8’s condition to be severe enough to require such services. AD further stated that she had no input in the decision to place R8 on or off hospice, as this was solely determined by the hospice providers. Despite F1's desire for hospice services, AD noted that R8 had been evaluated multiple times, and each time, hospice nurses concluded that R8 did not meet the criteria for hospice care.

A review of the records shows that R8 was discharged from Palliative Care Services on 11/18/2022, which aligns with AD's account that hospice services were withdrawn. This decision was reportedly based on the hospice nurses' assessment that R8 did not require hospice care. Additionally, AD mentioned that she had been actively working with the Ombudsman and hospice staff to address F1's concerns and ensure that R8’s medical needs were being met. However, F1 reportedly disregarded the facility's reports and recommendations, often expressing dissatisfaction and accusing the facility of withholding proper care.

Based on the gathered information, this allegation was UNSUBSTANTIATED. While there were conflicts between the facility and R8’s family member, particularly regarding R8's care and the provision of hospice services, there is insufficient evidence to support the allegation that facility staff interfered with R8's access to hospice. The decision to discontinue hospice services appears to have been made by the hospice nurses.

The allegation involves a potential unlawful increase in the cost of care for resident (R8), particularly concerning changes in R8’s care fees and related services. The investigation into this allegation consisted of interviews and record reviews of relevant documents.

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In an interview with the facility staff explained that R8's care needs had increased, which led to adjustments in their care plan and service charges. Initially, R8 was receiving level 1 care, but as their needs increased, the facility reassessed R8’s care requirements, resulting in a higher service rate. Staff stated that this increase was in line with R8’s changing medical condition and the need for additional services, including hospice care, which was also part of the rate adjustment. Staff noted that R8's family member, F1, had expressed dissatisfaction with the facility's decisions, particularly regarding hospice services and the associated costs.

A review of R8’s care plans from May 2021 and October 2022 confirms that there was an increase in both the care level and the cost of services. The care cost for R8 rose from $2,278 per month in May 2021 to $5,618 per month in October 2022, corresponding to the increase in care requirements. Additionally, a written notice provided to R8’s responsible party indicated that, effective 12/29/2022, the care rate would increase from $4,682 to $5,618, again citing the increased care needs. This notice aligns with the terms outlined in the facility's admission agreement, which specifies that the facility may adjust the rate of care services immediately if the resident’s needs change.

The facility’s admission agreement, signed by F1 on 6/6/2021, includes provisions for rate adjustments under Section 4(a), which states that the monthly rate for core services may be changed upon 60 days' notice, with adjustments reflecting changes in care needs. This agreement also provides for an annual rent increase of up to 4%. Additionally, it is outlined in the agreement that hospice services, if requested, would incur an additional fee of $700 per month, on top of any other applicable charges.

Furthermore, an examination of R8's rent history shows that the facility provided a written notice of a rent increase from $1,950 to $2,028, effective 8/1//2022. This increase is consistent with the facility’s practice of annual rent adjustments, as outlined in the admission agreement.

According to staff interview, R8 has a history of seizures, which appear to be short and atypical in nature, describing these seizures as involving a brief loss of motor function, with R8 freezing, rolling their eyes, and occasionally raising their arms before returning to baseline within 3-5 seconds. Staff noted that these episodes can occur during ambulation, potentially causing falls. One such fall involved R8 hitting their head after a seizure while walking, resulting in a hospital visit. Staff indicated that R8’s family member, F1, has been frequently argumentative about the resident’s care, particularly concerning R8’s medical diagnosis and treatment, including the administration of seizure medication and recommendations for hospice care. F1’s behavior has reportedly led to the discontinuation of hospice services for R8, as hospice nurses found it difficult to work with F1. Despite this, staff has consistently reported changes in R8’s condition to hospice and other involved parties, keeping a detailed paper trail with the Ombudsman and hospice staff.

Staff member S2, who works the 3 PM to 11 PM shift, confirmed an incident on the night of the fall. Although S2 did not witness the fall itself, S2 heard it and responded immediately. Upon entering R8’s room, S2 observed a cut on R8 head and noted that R8 appeared stable. S2 cleaned the wound and ensured R8 received further medical care after. S2 also communicated the incident to AD, who later instructed R8’s familiy member to take R8 to the hospital. S2 reported that while R8 was somewhat more confused than usual that day, he did not appear severely injured or bruised initially. S3, another staff member, corroborated that R8 does not often fall and has a history of seizures but was unsure of the specific causes of these episodes.

Reviewing the facility’s incident reports provides additional context. On 12/11/2021, R8 fell, resulting in a skin tear on right arm, but he did not report pain and was transported to the hospital for evaluation. Another fall occurred on 2/10/2022 while R8 was in the bathroom, leading to an unwitnessed fall with a resulting wound. A third report on 11/16/2022 indicated a fall with a minor bruise to R8’s upper right brow, and the Palliative Care Nurse was contacted to report the incident.

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Based on the gathered information, this allegation was SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met. However, while the resident’s fall and injury are concerning, they appear to be a result of his medical condition, which is known to cause brief seizures that can lead to falls.

California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.

During exit interview, LPA discussed plan of correction with Administrator; a copy of this report and appeal rights were provided.

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