Complaint Investigation Report

Allegation: Resident fell sustaining injuries as a result of staff negligence.

The details of the complaint alleged client #1 (C1) fell and sustained injuries due to staff negligence. The complainant reported (C1) fell out of bed between 12 am - 4 am and was found on the floor due to staff neglecting to care for the (C1) properly. The complainant stated (C1) later had bruises on the high cheek bone due to the fall. The complainant reported (C1) has a bed alarm that should have been activated to prevent this fall.

The Department interviewed staff on 11/01/23 between 10:00 am - 11:30 am (4) out of (4) staff #1-#4 verified a fall incident occurred on 09/26/23. (4) out (4) reported the incident happened between approximately 11: 45 pm through 4:30 am. According to staff #5 (S5), (C1) experienced agitation and restlessness for two nights and did not have full night's sleep. According to (C1's) sleep log, (C1) slept 3.5 hours on 09/24/23, 4 hours on 09/25/23, and 7.5 hours on 09/26/23 the day that (C1) had the incident. (S4) reported being notified by (S1) by text message at 6:15 a.m. on 09/26/23 of the fall incident. (S1) did a medical assessment of (C1) at the facility and notified the primary physician, family representative, placement agency, and community care licensing. On the same day, (C1) was transported to Urgent Care at Harbor UCLA Medical Hospital for further assessment. (C1) was discharged the same day with no new medication, lab work completed, and with no acute distress noted.

An interview with witnesses between 9:00 am - 1: 33 pm (2) out (2) witnesses #1 - #2 (W1-W2) were notified by a facility staff of the incident on 09/26/23. (W1) reported noticing a face bruising on (C1) 09/28/23 prompted (W1) of the fall incident on 09/26/23. (W2) recalled being notified by (S5) of the incident and did not offer further details on how many times (C1) had fallen off the bed on 09/26/23. (W2) stated not aware that a Health Plan of Care for (C1) was in place dated 07/29/23. The Plan was implemented to prevent falls and (C1) has a history of falls and seizures. The plan included padded bed side rails; low bed position; beside foam pad on the floor to prevent injury from falls, monitor, document, and report to medical doctor signs and symptoms of seizure activity.

The Department interviewed staff #1 (S1) on 11/01/23 at 12: 37pm -12:59 pm. (S1) recalled the incident with (C1) and claimed that (C1) had multiple falls from 12:00 am - 4: 30 a.m.