Complaint Investigation Report

A resident (Resident 1) sustained multiple falls at the facility .

During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, the Resident’s Assessment document and photos.

It was reported and verified by Incident Reports that a resident did sustain multiple falls at the facility. In one fall, it was reported that the resident suffered a head injury and a black eye (photo reviewed). The facility completed the Activities of Daily Living Basic Care Services for the resident. The checklist for item #3 states “How much assistance does the resident require with mobility and transfers?” A check mark is listed for “Walks with supervision or ambulation devise.” In addition, the resident’s Physician Report states that the resident has “Motor Impairment/Paralysis from post hip surgery, need assistance.” On the Appraisal/Needs and Services Plan it is stated “Functioning Skills – Difficulty in developing and/or using independent functioning skills, cannot function on own.” Three different documents supported that the resident was a fall risk and needed assistance and supervision when walking.

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