Complaint Investigation Report

In regard to the allegation: Facility did not have sufficient staff to meet residents' needs. The department reviewed Home Health records, Hospice records, Hospital records, interviewed Resident #1's (R1) primary physician, family member, Staff #1 to #6 and Resident #2 (R2) and #3 (R#). R1's home health nurse and primary doctor concur that R1 needed a one-on-one private care provider to monitor R1 while R1 was alone in R1's room. The facility was providing the highest level of care (maximum assist) for R1; however, the care provided was insufficient to meet resident needs and prevent R1 from falling. R1 was falling while alone in R1's private room and did not fall when being assisted by facility staff. Although the R1's family member were encouraged to obtain a private one on one care giver to assist, family member failed to do so and the R1 continued to fall while residing in the facility. The facility notified R1’s hospice agency of R1’s falls on 10/02/19, 10/03/19 & 10/04/19. After being notified of R1s falls, the hospice agency checked on R1s condition and found no injuries. Although the facility was not contractually required to provide a one-on-one care to R1, the facility failed to meet residents needs by not providing assistance to R1, who had prior falls that the facility was aware of. The information and evidence obtained during the investigation, sufficiently supports the allegation, thus this allegation is substantiated.

In regard to the allegation: Facility retained a resident requiring a higher level of care. The department reviewed Home Health records, Hospice records, Hospital records, interviewed Resident #1's (R1) primary physician, Family member, Staff #1 to Staff #6 and Resident #2 and Resident #3. R1's home health nurse and primary doctor concur that R1 needed a private care provider to monitor R1 on a one-to-one basis, while R1 was alone in R1's room. The facility was providing the highest level of care (maximum assist) for R1, yet the staff assistance was insufficient to prevent R1 from further falls, which occurred on 10/02/19, 10/03/19 & 10/04/19. R1 sustained falls while alone in R1's private room but did not sustain falls when being assisted by facility Staff. Although the R1's family member were encouraged by the facility to obtain a private one on one caregiver to assist R1, the family members failed to do so and R1 continued to fall in the facility. The facility was not contractually required to provide R1 with a one-on-one care and supervision, however, the facility failed to assist R1 in obtaining a higher level of care than the facility could provide to prevent further falls. The information and evidence obtained sufficiently supports the allegation, thus this allegation is substantiated.

Based on the department's interviews and record review, the investigation revealed: 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 and Chapter 8 are being cited on the attached LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Milca Osorio.