Complaint Investigation Report

Assessment (dated 06/25/20), Hospice Care Plan (effective 07/08/21), Hospice Notes (dated 07/09/21), Medication Administration Records (June 2021 thru July 6, 2021), Administrator's Certificate, Facility Sketch, Facility Sign-in/Sign-out sheets (June 2021 thru July 6, 2021), Daily Routine Schedule (June 2021 thru July 6, 2021), House Rules, Facility Staff In-service Training (dated 04/30/21, 07/08/21, 07/09/21, 07/12/21, 07/13/21, 07/14/21, 07/15/21, 07/28/21), Incident Reports (dated 01/19/21, 01/29/21, 03/13/21, 05/31/21, 06/09/21, 06/19/21, 06/27/21), facility staff work schedules (June 25, 2021 thru June 30, 2021), facility staff and residents’ rosters.

This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and assigned to Investigator Robert Kujawa. The investigation included interviews with medical services staff (Witness #1), family members (RP/POA), facility staff (A1, S1 – S5), and residents (R1 – R5) and a review of medical records (dated 07/01/21 – 07/08/21) from St. Mary Medical Center Long Beach.

Regarding Allegation #1 : Resident #1 sustained multiple falls at the facility based on a review of facility incident reports (dated 01/19/21, 01/29/21, 03/13/21, 05/31/21, 06/09/21, 06/19/21, 06/27/21). Resident #1’s last known fall was on 06/27/21, the resident sustained an injury for which the resident did not receive medical treatment until four (4) days later 07/01/21. Facility staff notified the resident’s physician and family members about the fall; and Resident #1 showed no signs of injury or complaint of pain and discomfort at the time of the fall on 06/27/21. Resident #1 began complaining of pain in their right arm on 07/01/21; and facility staff notified the resident’s physician who examined Resident #1 who requested that the resident be transported to the hospital’s ER. Resident #1 was transported and admitted to St. Mary’s Hospital on 07/01/21. Upon discharge from the hospital on 07/08/21, Resident #1 returned to the facility with a sling on their right arm after undergoing treatment. Interviews conducted of medical services staff and a review of hospital medical records (dated 07/01/21 – 07/08/21) documented Resident #1 sustained a closed fracture of neck of right proximal humerus diagnosis during their last known fall on 06/27/21. Interviews conducted of facility staff corroborated that Resident #1 had sustained multiple falls and received the proper care from facility staff following each fall. Facility staff took steps according to the resident’s fall-risk plan to try and prevent further falls by vocalizing resident to ask for assistance.