Complaint Investigation Report

The Department investigated the allegations that the resident sustained a fracture while in care.

The Department concluded staff failed to acknowledge R1’s bruising surrounding his left shoulder prior to an office visit at Kaiser Permanente (KP) on January 13, 2022. The Department obtained a copy of R1’s discharge notes from KP where R1 was diagnosed with distal clavicle displaced fracture and soft tissue swelling. Photos obtained shows purple and yellow bruises that extended from the back below the neck, and to the left shoulder blades behind the left armpit. Bruising was also present in the front left shoulder. Based on interviews with 6 staff, 1 of 6 staff was the only one to have any knowledge of R1 sustaining an injury while at the facility. Staff (S6) observed R1’s shoulder being bruised, and other staff was not aware of what happened. R1’s physician’s report indicates resident needs assistance with bathing and toileting.

AGPA investigated the allegation that the facility failed to meet reporting requirements.

Based on record review of R1’s discharge notes from January 13, 2022, R1 was admitted to KP for neck pain and bruising on left shoulder from fall that occurred on January 9, 2022. There are no records of the Department receiving an incident report of R1’s fall.

AGPA investigated Resident’s care plan is inaccurate.

Based on a record review of R1’s care plan dated May 17, 2022, AGPA observed boxes under “assistive devices” were checked on the care plan form. However, during the interview with staff indicated R1 does not need an assistive device and can walk independently. The box on the form was checked off incorrectly.

Based on The Department observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director.