Complaint Investigation Report

The investigation consisted of the following: LPA conducted the initial 24-hour visit and requested copies of pertinent documents. The complaint was accepted by CCL IB Investigation Unit and assigned to IB investigator Heidy Bendana. IB investigator Bendana conducted and completed the investigation which included interviews with Assistant Administrator, facility staff, residents, resident R1’s conservator, Social Worker Director at Edgewater Skilled Nursing, and Harbor UCLA Medical Center Clinical Social worker, reviewed Harbor-UCLA Medical Center Medical Records, and resident R1 facility records.

Allegation: Resident sustained a fracture while in care

It is alleged staff failed to supervise Resident R1 resulting in hospitalization for a fracture.

During file record review it was notated R1 is independent. R1’s Physicians Report indicated R1 was “Able to Leave Facility Unassisted,” Able to Bathe, Dress, Groom, and Feed Self,” and did not require assistance with using the restroom or transferring. Appraisal/Needs and Services Plan listed R1 as ambulatory with the capacity to self-care and able to do all ADL’s, there was no indication that R1 was a fall risk. R1 was not feeble or slow and did not require assistance. During interviews with Staff S1-S3, they were asked, by the IB investigator, if R1 required assistance, three (3) out of three (3) stated R1 is independent and did not require assistance. Additionally, Staff (S1-S3) were asked if they were aware of R1 falling, three (3) out of three (3) stated they did not know R1 experienced a fall until R1 reported it to the hospital. During an interview with Staff S2, told the IB investigator, on 04/26/23 R1 was in their rocking chair, their face droopy, their speech was stuttered and not normal, therefore S2 called 911. S2 was informed