Complaint Investigation Report

This investigation was completed by Investigator Hector with the Investigations Branch and revealed the following:

Allegation: Resident sustained a fracture while in care. It is alleged that due to neglect/lack of supervision, R1 sustained a fracture in care. During the investigation, IB Investigator Hector contacted the Ombudsman office and the Sheriff Department; neither agency investigated the incident. A facility staff (S1) that witnessed/discovered the resident fallen and submitted internal Incident Reports was interviewed. The Incident Reports confirm that R1 sustained 6 unwitnessed falls. S1 revealed that prior administration instructed facility staff to “do more safety checks” and have R1 present in the dining room more where there was more staff supervision. However, there were no additional treatment plan changes to justify keeping R1 after continuing to sustain more falls. The current facility administrator was unable to provide any documentation from the prior administration regarding treatment plan changes. Moreover, the current facility administrator confirmed the facility does not have the staff to provide 1:1 supervision and the staff to provide the proper level of supervision for R1. The medical records confirmed that R1 sustained a hip fracture. There is sufficient evidence to support the facility had a lack of supervision of R1 that resulted in R1 sustaining injury; therefore, the allegation is SUBSTANTIATED.

***An immediate civil penalty will be issued today, in the amount of $500 due to neglect/lack of supervision of R1 that resulted in R1 sustaining a left hip fracture. ***

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date.

An exit interview was conducted, and a copy of this report was provided to Subashsani Kumar, Executive Director along with the Appeal Rights.