Complaint Investigation Report

Allegation: Staff left resident on floor for an extended period of time

During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. Review of R1’s admission agreement showed he was first admitted at the facility on 11/25/24 in the Memory Care unit with a primary diagnosis of dementia. Responsible party (POA) stated that on 11/29/24 at approximately 11:30PM, she received a couple of voice messages from staff (S1) advising her that R1 had an unwitnessed fall in his room at around 10:30PM, was confused & lethargic and had blood on his left elbow. Review of hospital discharge summary report dated 11/30/24 to 12/07/24 showed R1’s was admitted for altered mental status due to dementia precipitated by dehydration rhabdomyolysis (muscle weakness due to a fall & can’t get up for an extended period of time). POA stated that R1 goes to bed at around 8PM daily. Review of incident report dated 11/29/24 showed R1 had an unwitnessed fall on 11/29/24 at around 10:30PM when the night shift staff conducted their status check rounds in the memory care unit. 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 staff left resident on floor for an extended period of time was found to be substantiated.

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.