Complaint Investigation Report

Allegation #1: Resident sustained a fracture while in care. Staff members 1-6 (S1-S6) stated resident sustained a fracture while in care from a fall. The facility had no control over the fall and could not have prevented the resident from falling. The resident was in his bedroom in his recliner chair after breakfast and had an unwitnessed unforeseen fall. The facility staff immediately went to the resident's bedroom to check on the resident and provided assistance. The hospice nurse called 911 immediately and paramedics transported the resident to the hospital where he was diagnosed with a left femur fracture. S1-S6 stated that the facility staff are well-trained, adhere to Title 22 Regulations, and took all necessary precautions.

Allegation #2: Facility failed to meet report requirements

Staff 1-6 (S1-S6) members interviewed stated a written special incident report (SIR) was reported and submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. Staff 1-2 (S1-S2) stated this report includes the resident's name, age, sex, date of admission; date and nature of the event; attending physician's name, findings, and treatment, and disposition of the case. S1-S2 stated a follow-up SIR was also reported regarding the death of the resident, the cause of death, and where the death occurred. S1-S2 stated that the incident did not occur because of neglect and lack of supervision. S1-S6 stated staff could not have prevented the fall from happening. S1-S6 denied the allegation.

Allegation #3: The facility did not notify the resident's POA of an incident

Staff 1-6 (S1-S6) stated that the facility gave the resident’s information to the paramedics and Long Beach Memorial Hospital. The hospice nurse and Administrator came to the facility immediately after the resident had fallen. The Hospice nurse and the Administrator informed the resident POA of the incident. The staff is not aware of how long it took the POA to locate the resident. The Administrator stated they give the paramedics the resident, physician reports, medications, and contact information. The Administrator stated they reported the Special Incident Report and informed Community Care Licensing and all the appropriate agencies in a timely manner.