Mental Health / Public Guardian

On February 3, 2003, the Office of the Public Guardian recommended that the Client be placed at Villa La Roe (VLR), describing that facility as “a facility that provides care and treatment for persons suffering from dementia and need assistance with their daily living activities”. The officer making that

As required under Title 22, Article 6, Section 87584 (Functional Capabilities) the RCFE did not assess the Clients need for care and ability to perform the function of daily living. The Client was hard of hearing, had no dentures, stopped eating, drinking and taking medication. The RCFE Administrator and staff did not report these changes to the DMH Case Manager, conservator or physician.

In mid-June 2003, a Clinical Nurse from the Hemet Mental Health Clinic temporarily replaced the Client’s regularly assigned RN/Case Manager. On June 16, 2003, this Clinical Nurse called the Facility’s Administrator to discuss the Client’s condition. The Facility Administrator reported that the Client was “stable, doing well, eating okay and taking prescribed medication.”

On June 23, 2003, a Clinical Nurse, and a Behavioral Health Specialist from the Hemet Mental Health Clinic made an unannounced visit to the VLR to meet the Client and Facility Administrator. Pursuant to Welfare & Institution Code, a Clinical Nurse is a mandated reporter. (a) “Any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that person receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care 5 custodian, health practitioner, or employee of a county adult protective services agency or a local law enforcement agency is a mandated reporter.” Source: Welfare & Institutions Code, Chapter 11, Article 3, Section 15630 Mandated Reporter. They were greeted by an 18-year old male staff member, who escorted them to the Client’s room. The male staff member informed the nurse, “The Client had not eaten for 4-5 days”. The Clinical Nurse and Behavioral Health Specialist entered the Client’s room and observed the following conditions: a. No bedding. b. Client lying half off the bed on right side, legs dangling on floor. c. Nude from waist down. d. Disoriented. e. Client moaning, “I’m in pain, I’m diabetic”. f. A bowl of applesauce on the dirty un-vacuumed carpet. g. Feces smeared towels littered on the bathroom floor.

The Clinical Nurse immediately called “911” and the Client was transported by ambulance to SGMH for emergency medical care. The Clinical Nurse did not report the conditions described in 4a – 4g despite provisions of Mental Health Policy #218, that required reporting of possible elder abuse and neglect.

The emergency room physician at SGMH stated that the Client had “severe urinary tract infection (urosepis) with mild dehydration and possible neglect and abuse”.

After the emergency room physician evaluated the Client and established a diagnosis, the Client was admitted to SGMH for treatment and care. The Client’s medical condition did not improve and subsequently died on July 1, 2003.

The social worker at SGMH reported the possible neglect and abuse. Adult Protective Services did not intervene.

VLR Administrator and staff failed to seek medical attention for the Client even after staff observed that the Client would not eat, drink or take medication and was losing weight rapidly. 6

The Department of Mental Health failed to advise the Office of the Public Guardian that Dementia Probate Conservatorship had been approved for the Client on March 27, 2003.

The Office of the Public Guardian neglected to consult with CCL regarding the licensee status or suitability of placement for dementia residents at VLR (RCFE).

Evidence shows that the Policies and Operating Procedures that were established in 1988 in the PG’s Policy and Procedure Manuals have not been updated since 1998. Current Operating Procedures are not reflected in the manual.

VLR violated Article 3, Section 87227 of the CCL Manual Policies and Procedures by failing to surrender all cash (from Client’s spending account) resources, personal property and valuables to the Office of the Public Guardian upon the death of Client.

On July 7, 2003, a CCL Licensed Program Analyst conducted an investigation at Villa La Roe and substantiated “client neglect care” allegations through the examination of RCFE documents.

The following data summarizes deficiencies documented by CCL at Villa La Roe from February 14, 2002 through September 19, 2003. . 7

Table I summarizes the deficiencies that were found by Licensed Program Analyst (LPA), CCL. Table 1 FACILITY DEFICIENCIES OBSERVED BY CCL DURING UNANNOUNCED VISITS AND INSPECTIONS DATE CODE VIOLATION INSPECTION DEF DESCRIPTION TYPE 2/14/02 87101 (r)(4) Case A Non-Compatible Residents Management Exceeded the number of allowed adults (ages 18-59) living in this elderly facility. 3/25/02 87575 (h)(2) Case A Medication & Centrally Stored Management Medication Records Prescribed medication for one resident was found on the top of a filing cabinet in an office with the door unlocked. 87575 (a)(6) A The RCFE did not consistently or adequately monitor a resident’s self- administered medication. A A bubble pack prescription for one resident had pills missing. The RCFE was not consistent in assisting residents with self-administered medication. 87575 (h)(6) A A resident’s medication was not A,B,C,D,E,F properly documented on the Centrally Stored Medication Record. DATE CODE VIOLATION INSPECTION DEF DESCRIPTION TYPE 4/5/02 87703 (b)(3)(B) Case A Oxygen Administration Management The RCFE does not have the required signs posted which reads “No Smoking Oxygen in Use”. 87703 (b)(3)(E) A Four (4) oxygen tanks were placed in bedroom #2 without being secured in a stand or to the wall. 87575 (b)(3)(F) A An unauthorized extension to the standard seven (7) foot plastic tubing from nasal cannula on mask to the main source of the oxygen tank 11/08/02 87691 (i)(A)(B)(C) Annual A Maintenance and Operations The signal system in a resident’s bedroom was inoperative. 87691 (a) A The Carpeting in a resident’s room and throughout the common areas of the facility was dirty and stained. 87691 (a) A Toilet seat in a resident’s bedroom was loose and not secured to the toilet seat. 87691 (a)(b) A Door leading to the outside of a resident’s room was not properly fitted to the frame, allowing cold air to enter. DATE CODE VIOLATION INSPECTION DEF DESCRIPTION TYPE Maintenance and Operations 11/08/02 87691 (a)(b) Annual A Cold Air coming through the vents of the air conditioning units located in a resident’s window. 87691 (a)(e)(5) B The floor mats in a majority of the resident’s bath tub/shower were dirty and worn. A Freezer in hallway blocking the exit to a resident’s bedroom. Personal Rights 03/01/03 87572 (a)(1,2,3) Case A An elderly resident was sharing a Management room with an adult resident (under 60) who was loud, confrontational and intimidating with other residents. Definitions: “Residential Care Facility for the Elderly” 87101 (r) (4) A The facility exceeded the number of adults (ages 18-59) allowed to be living with the elderly. Personal Accommodation & Services 03/10/03 87677 (A)(2)(C) Case A One resident was using another Management resident’s bedroom as a passageway to the bedroom and toilet. Limitations 87582 (B)(6) A Three adult residents yelled, cursed, threatened staff, and intimidated the elderly population living in the RCFE. Care of Persons with Dementia 03/11/03 87724 (c) A An elderly resident was not able to demonstrate with mental competence or physical ability that she could exit the facility in case of an emergency. Medical Assessment 07/07/03 87569(a)(b)(1)(2)(4) Complaint Facility transfer document on files Investigation dated 2/27/03 revealed that EM had a diagnosis of diabetes and was prescribed” sliding scale insulin” yet medical assessment on file at facility completed by the physician makes no mention of diabetes or what diabetic care is required Incidental Medical & Dental Care 07/02/03 87575 (a)(1) Complaint A The RCFE administrator and/or staff Investigation failed to seek appropriate medical care for the resident EM when she stopped eating, drinking and taking medication. Observation of Resident 87591 Resident A The RCFE did not provide appropriate Observation assistance in a timely manner when a resident’s condition was deteriorating and she was loosing weight. Maintenance & Operations 09/10/03 87691 (1) Case A The RCFE’s stove/oven in the kitchen Management was not in proper working condition. The oven thermostat was inoperative resulting in incorrect oven temperature. Provisions & Upkeep of Regulations 09/10/03 Health & Safety Code Case A There was no proof on file that the 1569.155 Management licensee subscribed to an appropriate regulation subscription services. Food Service 87576 (b)(26) B There was an insufficient supply of perishable food on hand to meet the needs of 14 residents for two (2) days. Maintenance & Operations 09/19/03 87691 (a) B The flooring in one resident’s bedroom had numerous missing tiles and the area where the tiles were missing was dirty. 09/19/03 87691(a) The carpeting in six (6) resident’s bedrooms was dirty, worn and stained. A citation for this violation was issued on 11/08/02. Type A: Deficiency Violations of the regulations and/or Health and Safety Codes, that if not corrected, has a direct and immediate risk health, safety and personal rights or clients in care. Type B: Deficiency Violations of the regulations and/or the Health and Safety Codes that, without correction, could become a risk to the Health, safety or personal rights of clients, a record keeping violation that would impact the care of clients and/or protections of their resources, or a violation that would impact those services required to meet the client’s needs. 13

who was loud, confrontational and intimidating with other residents. Definitions: “Residential Care Facility for the Elderly” 87101 (r) (4) A The facility exceeded the number of adults (ages 18-59) allowed to be living with the elderly. Personal Accommodation & Services 03/10/03 87677 (A)(2)(C) Case A One resident was using another Management resident’s bedroom as a passageway to the bedroom and toilet. Limitations 87582 (B)(6) A Three adult residents yelled, cursed, threatened staff, and intimidated the elderly population living in the RCFE. Care of Persons with Dementia 03/11/03 87724 (c) A An elderly resident was not able to demonstrate with mental competence or physical ability that she could exit the facility in case of an emergency. Medical Assessment 07/07/03 87569(a)(b)(1)(2)(4) Complaint Facility transfer document on files Investigation dated 2/27/03 revealed that EM had a diagnosis of diabetes and was prescribed” sliding scale insulin” yet medical assessment on file at facility completed by the physician makes no mention of diabetes or what diabetic care is required Incidental Medical & Dental Care 07/02/03 87575 (a)(1) Complaint A The RCFE administrator and/or staff Investigation failed to seek appropriate medical care for the resident EM when she stopped eating, drinking and taking medication. Observation of Resident 87591 Resident A The RCFE did not provide appropriate Observation assistance in a timely manner when a resident’s condition was deteriorating and she was loosing weight. Maintenance & Operations 09/10/03 87691 (1) Case A The RCFE’s stove/oven in the kitchen Management was not in proper working condition. The oven thermostat was inoperative resulting in incorrect oven temperature. Provisions & Upkeep of Regulations 09/10/03 Health & Safety Code Case A There was no proof on file that the 1569.155 Management licensee subscribed to an appropriate regulation subscription services. Food Service 87576 (b)(26) B There was an insufficient supply of perishable food on hand to meet the needs of 14 residents for two (2) days. Maintenance & Operations 09/19/03 87691 (a) B The flooring in one resident’s bedroom had numerous missing tiles and the area where the tiles were missing was dirty. 09/19/03 87691(a) The carpeting in six (6) resident’s bedrooms was dirty, worn and stained. A citation for this violation was issued on 11/08/02. Type A: Deficiency Violations of the regulations and/or Health and Safety Codes, that if not corrected, has a direct and immediate risk health, safety and personal rights or clients in care. Type B: Deficiency Violations of the regulations and/or the Health and Safety Codes that, without correction, could become a risk to the Health, safety or personal rights of clients, a record keeping violation that would impact the care of clients and/or protections of their resources, or a violation that would impact those services required to meet the client’s needs. 13