Complaint Investigation Report

Staff did not safeguard resident’s incident report - SUBSTANTIATED

LPA reviewed 3 internal incident reports dated 10/02/2022,10/03/22, and 10/07/2022. In the reports dated 10/02/2022 and 10/03/2022 R1 was found on the floor next to their recliner. The report dated 10/07/2022 did not specify where R1 was found other than “on the floor.” None of these unwitnessed falls were reported to licensing.

During staff interviews 1 of 6 staff stated that the incidents were reported to the manager. 5 staff stated they did not know if the incident was reported.

Administrator stated If residents are OK with no injuries and they don’t go to the hospital then we just do an internal report. We have a report on 10/03/22 that R1 fell out of their recliner. The family said EMTs were not needed so R1 was not sent out. Any time the EMTs assess R1 and say R1 doesn’t need to go out to the hospital we don’t report it. Staff hand fills out a report, it is given to me, and then I decide if it needs to be reported to CCLD. They are trained on the process.

It was determined that staff are reporting incidents via internal report to the administrator. If the resident does not go out to the hospital the report is not being sent to CCLD. The facility needs improvement on their incident reporting process and the requirement to report to CCLD therefore this allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Melissa Morales.