Complaint Investigation Report

Resident fell sustaining a fracture due to staff neglect

During the course of the investigation, R1’s medical records indicated that she was admitted to the hospital on August 3, 2024, due to pain in her left shoulder from a fall. She was discharged on August 7, 2024, with a diagnosis of a scapular fracture in her left shoulder. On August 11, 2024, R1 was re-admitted to the hospital for pain in her left shoulder following another fall, with the same diagnosis of scapula fracture. R1’s physician's report, dated May 21, 2024, did not indicate a diagnosis of dementia. According to R1’s Appraisal Needs and Service Plan, she requires assistance with ambulation and transfers to and from the bathroom; this was especially important at night. Interviews with R1 and staff revealed that S2 was the only staff member on duty during the overnight shift when the incidents occurred. R1 stated that S2 placed her on the commode and left her there for an extended period. S2 explained that during the time R1 was on the commode, she had to assist two other residents.

Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . Health and Safety Code are being cited on the attached LIC809D.

A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending. A formal conference with CCLD will be scheduled at a later time .