Complaint Investigation Report

On 04/01/22, the El Segundo Adult Senior care referred the above assignment to the Investigations Branch. It was accepted as an assignment to interview Resident R1 and administrator. Investigator Laura Garcia conducted interviews with the former Administrator on 04/05/22 and R1 on 06/01/22.

The investigation revealed the following:

Allegation: Staff do not supervise residents resulting in multiple falls

It is alleged as a result of being short staffed resident fall due to lack of supervision.

During file review, LPA reviewed Special Incident Reports (SIR) regarding falls. During the facility tour, LPA observed some rooms have a lower bed to make it easier for residents to get in and out of to help prevent falls. Additionally, LPA observed some rooms have fall mats that are placed next to the bed once the resident is in bed.

During interviews with Staff S1-S8, were asked how often are residents with fall plans checked on, eight (8) out of eight (8) stated they are checked every fifteen (15) minutes.

During interviews with Residents R3, R5-R16, were asked if they have had any falls while living in the facility, nine (9) out of thirteen (13) stated they have not had any falls while living here. Three of the four residents who experienced falls stated the falls happened years ago, and the other stated theirs was a minor fall. Additionally, during interviews with Residents R3, R5-R16, were asked if they feel staff supervise residents, thirteen (13) out of thirteen (13) feel staff supervise residents.