Complaint Investigation Report

Allegation: Resident fell and sustained a fracture due to staff neglect.

The details of the complaint alleged that a resident sustained fracture due to facility staff neglect.

On 11/6/23, complaint was accepted by IB for a full investigation and assigned to Special Investigator Lorraine Patterson. As part of the investigation, investigator Patterson obtained the (R#1)’s facility file, (R#1)’s medical records from Centinela Hospital, (R#1)’s interview, facility staff interview(S#1-S#2), witnesses’ interviews(W#1-W#2), facility administrator interview(A#1) and an Attempted contact with Reporting Party (RP)

Investigator Patterson conducted the following based on interviews.

On 12/11/23, Investigator Patterson spoke with Administrator (A#1), she stated that she does not suspect any neglect which led to (R#1)'s fall and subsequent fracture while in care. She maintained that during the time of their back-to-back falls on 05/2/23 and 05/03/23, they were medically and physically stable, and there was no change in their baseline that contributed to their fall. According to her, (R#1) was able to "push" themselves around and ambulate in their wheelchair while in care. (R#1) could call for help and make their needs known.

On 12/11/24, Investigator Patterson spoke with facility staff (S#1 and S#2), (2) out of (2) denied neglect/lack of supervision and care contributed to (R#1)’s falls that lead to (R#1)’ fractures.

On 12/11/24, Investigator Patterson spoke with residents in care (R#2 and R#3), (2) out of (2) state that they denied suspecting and or witnessing neglect from facility staff contributed to (R#1)’s falling sustaining a fracture or injury.