Complaint Investigation Report

Allegation: "Reporting Requirements". Resident (R1) returned to the facility from a Skilled Nursing Facility (SNF) on April 1, 2022. It is alleged that on 4/3/2022 the resident had an unwitnessed fall and was not sent to the hospital for further evaluation. Staff interviews indicated that if a resident falls and hurts themselves they are sent to the hospital for an evaluation. Administrator stated that sometimes residents refuse to go to the hospital, 911 Emergency is called anyway for an evaluation, and if the resident refuses they are not transported. Resident (R1's) Durable Power of Attorney stated incidents are reported in a timely manner. In regards to the incidents addressed on this complaint resident (R1) fell on 4/3/2022 but did not require medical treatment. An Incident report regarding resident (R1's) fall was completed, but not faxed to Licensing. A copy was obtained.

It is alleged resident (R1) sustained a minor toe injury because staff (S1) accidentally stepped on the resident's toe during bed transfer. The resident stated that it did not report the injury to any staff and they were made aware of the injury until 4/4/2022. Resident (R1) could not recall when the toe injury occurred. On 4/4/2022 a home health staff observed the toe injury and reported it to Administrator and staff (S1). Facility staff were not aware of the toe injury. As of 4/12/2022 an incident report had not been submitted to Community Care Licensing. LPA obtained a copy of the toe injury incident report during 4/15/2022 site visit, past the seven days Title 22 reporting requirement. Administrative Assistant staff acknowledged that it forgot to send the toe injury incident report.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited. See LIC 9099D.

Exit interview was conducted with Administrator Kim Commodore. A copy of the report and appeal rights were provided.