Complaint Investigation Report

Allegation #2: Staff did not supervise residents resulting in multiple falls and injuries.

Regarding the allegation “Staff did not supervise residents resulting in multiple falls and injuries.” It is being alleged that resident was admitted to Torrance Memorial Hospital, on 12/4/21, for a fall that result in a left hip fracture and a left femur fracture. This investigation revealed resident #1 (R1) was admitted to Senior Living Lifestyle – Palos Verdes on 07/24/21. An interview was conducted with Licensee/Robert Smith who stated R#1’s first fall occurred approximately (1) week after R#1’s admission. The department found this fall resulted in serious injuries to the head, hip, and ribs. The Licensee stated that during R#1’s admission to the facility, R#1 was assessed and deemed a “fall risk”. The Licensee stated that after the fall in August of 2021, the facility failed to employ a fall risk plan. The department found on 12/01/21, R#1 fell again at the facility and the fall resulted in a hip and femur fracture. The Licensee stated after the second fall occurred preventative measures were put in place for R#1 when R#1 returned to the facility from skilled nursing in January of 2022. The department conducted and interview with R#1 and R#1 did not recall the falls that occurred while residing in the facility. Based on the departments review of medical records, supporting documentation, and interviews conducted; the department found the facility failed to provide R#1 the appropriate level of care and supervision and this resulted in R#1 sustaining injures due to falls.

Allegation #3: Facility did not seek timely medical attention for resident.

This complaint alleges that the facility did not seek timely medical attention for Resident R1 after R1 fell and sustained serious injuries on 12/1/21.

On 12/01/21, Resident (R#1) fell at the facility, and this resulted in a left hip and femur fracture. The department conducted an interview with Licensee/Robert Smith, who stated he contacted 911 following R#1’s fall; however, the department was unable to find records of this call.