Complaint Investigation Report

The investigation revealed the following. Regarding Allegation: Staff did not properly transport client, resulting in client sustaining an injury- It is alleged that on 05/05/2024, C1 was sitting in the facility wheelchair and was being wheeled to the dinning room table by S1. As C1 was being wheeled, C1’s right foot got caught under the wheelchair’s right tire. C1 made a sound that alerted S1 and S1 stopped the wheelchair and noticed C1’s foot was caught by the right wheel. S1 immediately did a body check on C1 and did not observe any swelling, bruising, damage to skin or color change was observed. Administrator Nacua was notified by S1 via phone and Administrator Nacua arrived shortly after to assess C1. Administrator Nacua did not observe any swelling, bruising, or damage to skin. On 05/06/2024, Administrator Nacua and staff observed C1’s right ankle swollen and appeared to bruised. Administrator Nacua took C1 to Foothill Presbyterian ER and it was revealed C1 was diagnosed with minimally displaced fracture of the medial malleolus (lowest part of the tibia, or inner bone of the ankle). During LPA’s interviews with staff and client record review, it was revealed that C1 has been residing at the facility since 2007. C1 was accepted into the facility with their own custom-built wheelchair. Per interviews with staff, C1’s custom wheelchair is significantly taller than the facility dining room table. Staff would transport C1 from their custom-built wheelchair to the facility wheelchair so that C1 could enjoy their meals with the rest of the clients. According to staff interviews, staff has been transporting C1 to the dining room table in this manner since C1 arrived at the facility and there has been no prior incidents of C1 receiving injury while being transported in this manner. During facility tour, LPA Ramirez measured the height difference from C1’s custom-built wheelchair and the facility dining room table. LPA Ramirez observed there to be a 1ft difference between the height of C1’s custom-built wheelchair and the facility dining room table. LPA Ramirez measured the height difference between the facility wheelchair and the facility dining room table. The facility wheelchair and dining room table were observed to be at the same height. Although staff has been utilizing the facility wheelchair to transport C1 to the dining room table, C1’s custom-wheelchair has detachable elevating legrests/footplates for C1’s dangling feet. The facility’s wheelchair was not equipped with these legrests/footplates on 05/05/24, which could have prevented C1’s injury. Due to C1 being nonverbal and suffering from cognitive impairments, LPA Ramirez could not able to conduct interview. Based on interviews and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . LPA Ramirez will issue Type A deficiency. LPA Ramirez consulted Administrator Nacua on different wheelchair trays or adjustable wheelchair tables that can be utilized in the future to avoid removing C1 from their custom-built wheelchair when dining at the facility.

One (1) deficiency has been issued during this complaint investigation. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided via email due to printer problems.