Complaint Investigation Report

During this virtual, video conference call with Administrator Larin, LPA Soto also conducted a virtual physical plant tour of the facility. A separate investigation was conducted by Department of Social Service Investigator (Douglas Real) which included review of medical records, hospital records, home health agency records, interview with facility staff and medical services staff.

Regarding Allegation #1 : This investigation revealed that Resident (#1) (referred to as R1) sustained a displaced fracture to the left femur based on x-rays done on 02/28/21. Facility staff informed the hospital that Resident #1 did not have any falls or known trauma. Facility staff were aware of the discoloration (bruising) at the fracture site for several days (between 02/20/19 – 02/28/19); but unaware of the cause of the fracture. No other external injuries were found. Interviews conducted with the Regional Center’s Physician Assistant, RN, and LVN; including Resident #1’s primary care physician – who regularly saw the resident in the facility, none reported knowing the cause of the fracture nor did they suspect intentional abuse or neglect. Resident #1 is non-verbal and unable to provide any information; however, the primary care physician speculated that the injury was accidental and most likely occurred while facility employees transferred the resident into or out of bed with the Hoyer lift. No intentional abuse or neglect was uncovered during this investigation. Based on the evidence gathered and interviews conducted and records reviewed, did not concur with the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

An exit interview was conducted with Yvette Velasquez, DSP and a hard copy of report was provided.