Complaint Investigation Report

Harbor Regional Center Individual Person-Centered Plan (IPP) dated: 09/05/24 for C1 was provided to the department on 10/25/24. A health and safety check and a tour of the entire facility was conducted with Administrator Sharon Hopper. Interviews were conducted with staff #1-#5 (S1-S5), witness #1-#2 (W1-W2) and attempted to interview clients #1-#3 (C1-C3). The department was unable to interview staff #6 (S6) as they are no longer employed by the facility and was unable to reach them. Additionally, the department requested for a fall risk plan for C1, but according to Administrator Sharon Hopper, they do not have one available.

Allegation: Client sustained fractures while in care due to staff neglect . It is being alleged that a client sustained fractures after a fall due to neglect. The department conducted a review of records and found that it was noted on the facility’s Service Notes for Current Residents that on 04/18/24 C1 was attempting to open the fridge and staff redirected C1 to go to the living room. C1 then took a step from the sunken (one-step) kitchen to the hallway and fell on their buttocks, resulting in a small bruise. Staff then reported this incident to Administrator Sharon Hopper, and she instructed staff to administer first aid. A review of the MAR for April 2024 for C1 revealed Ibuprofen (800mg) was administered to C1 on 04/18/24 and 04/19/24. An Unusual Incident Report (dated: 04/24/24) was submitted to the department reporting that on 04/23/24 C1 was taken to the hospital after staff noticed bruising and swelling on C1s lower back. According to records from Torrance Memorial Medical Center, C1 was admitted to the hospital on 04/23/24 for acute rib fractures and traumatic hemothorax that required an immediate chest tube insertion. An Unusual Incident Report (dated: 04/30/24) was submitted to the department reporting on 04/30/24 C1 was discharged rom the hospital with home health for physical therapy. A review of the Residential Health Care Plan (dated: 08/20/23) states that C1 is a fall risk under the section Problems, Needs, Concerns, and the facility’s approach to this concern is by monitoring C1 daily, making sure that C1 always wears appropriate footwear (socks, with grips on bottom, shoes that fit comfortably and not loose). A review of the Harbor Regional Center’s IPP (dated: 09/05/24) for C1 states that staff must be close by C1. If staff turn their back, C1 will do a sudden movement and that will cause C1 to fall.

During two unannounced visits, the department observed minimal light inside the facility. No lights were turned on and only natural light from the windows illuminated the home.