Complaint Investigation Report

During the investigation process, it was reported that staff assist the resident (Resident 1) in her daily activities to include transferring from the wheelchair to the toilet. In the past, the resident was able to bear her own weight by assisting with the transfer by grabbing onto the grab bar and using her good arm to set herself down or pull herself up off the toilet. On the day of the incident, 10/03/24 the resident appeared to be too weak to use her arm during the transfer. It was reported that it was common knowledge to the staff that the resident’s one arm was immobile because of a childhood diagnosis. During the transfer, the two staff persons went “arm-to-arm” with the resident and then heard a “popping” sound come from the resident’s arm. The resident said “ouch” and the staff asked her if she was all right. The resident responded that she was fine; however, was known not to complain.

The following day on 10/04/24 the resident complained to staff that her arm was hurting and that she was in pain. A determination was made to send the resident to the hospital for an evaluation. It was reported that during the toileting transfer, the resident sustained an acute, displaced, and impacted fracture of the right humerus neck.

According to the facility’s service plan, it states that staff may use a “gait belt for all transfers for safety of a resident.” During the interview process, it was stated that residents should not be pulled by the arm during transfers. Staff admitted they were not trained to use arm-to-arm transfers. A gait belt was not used during the transfer.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

The administrator was informed that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49. This report and rights to appeal were discussed with the administrator.