Complaint Investigation Report

Allegation: Resident sustained an unexplained fracture while in care

During investigation, the department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2) & R1’s responsible party (POA) and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 03/08/24 and resided at the facility for a couple of months. R1 was assessed as having dementia, ambulatory with a walker, needs assistance transferring in & out of bed, dressing and a high risk for falls. On 04/14/24, R1 was diagnosed with a displaced fracture of the left wrist. R1 stated that she hurt her left wrist at the facility when she fell out of bed. Staff (S1, S2) stated R1 had three falls at the facility (2 unwitnessed falls at night and one unwitnessed fall in the daytime) while at the facility. S2 stated that he found R1 on the floor on 2 separate occasions. R1 did not complain of any pain and helped her get back to bed. S2 confirmed that there were no fall precautions in place after R1’s repeated falls and that her repeated falls were not documented. 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 resident sustained an unexplained fracture while in care was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining unexplained injuries while in care. Additional civil penalty determination is pending relating to resident’s serious bodily injury.

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.