Complaint Investigation Report

Allegation: Resident was physically assaulted by an unknown perpetrator causing bruising.

The details of the complaint alleged client went to hospital with facial bruises due to physical assault by an unknown perpetrator.

During record review, LPA reviewed C#1's Physicians report for residential care facilities for the elderly (LIC 602A). LPA found that C#1 is ambulatory, not confused, has not have a wondering or sun downing behavior, can follow instructions, and can leave the facility unassisted. The only assistance C#1 needs from staff is managing her medication. In addition, LPA reviewed C#1's functional capability assessment (LIC 9172); she does not need assistance with dressing, grooming, bathing, and other personal hygiene. Also, the appraisal needs and services plan (LIC 625) states that C#1 presents with adequate independent functioning skills and maintains satisfactory daily living activities. The discharge hospital summary says C#1 prior level of function C#1 was in functional mobility and ambulation with no AD. LPA reviewed C#1's admission agreement rules and stated that all residents should abide by the facility's general rules. LPA asked the administrator for a copy of the facility rules. The general facility rules states, "All residents are encouraged to be back at the facility by 11:00 PM for their own safety."

During an interview with administrator Gabriela Chavez (A#1), she stated that on 7/12/2023, around 6:30 AM received a phone call from one of the staff saying that she saw C#1 coming into the facility "bruised up." The staff asked C#1 what happened to her; she replied: "I need to go to my room and wash my face." Immediately, the staff stopped C#1 from going to her room and called paramedics. When I arrived at the facility, EMS was already taking C#1 to the hospital. That day, I called her family and primary physician to let them know what happened to her. After C#1 was discharged from the hospital, we have been taking a closer look on her. I have been speaking with her sister and primary physician, they both believe C#1 needs a higher-level care facility. On 7/25/23, C#1 primary physician came to assess her and update her LIC 602; he is still working on it. In addition, the facility's home health nurse, that comes Monday through Friday, already assessed C#1 after she was discharged from the hospital. LPA asked the administrator about facility rules regarding leaving the facility after late hours or curfew time; the administrator stated that since most of the residents are independent and not living in a locked facility, we cannot tell them not to go out; we can only encourage them not to go out to the street at later hours. The only residents with restricted hours are the ones with parole orders and sex offenders.

Evaluation Report Continues on LIC 9099C.