Complaint Investigation Report

Allegation: Facility staff did not follow reporting requirements.

On 10/05/2022 R1 fell around 11:00 P.M., and did not receive staff assistance until the following day near breakfast time around 7:45 A.M., When staff brought up R1 breakfast that is when staff contacted the nurse and Med Tech to come and assist R1. R1 reported staff offered to send R1 to the hospital but R1 refused and decided not to go to the hospital. Staff was unable to prevent the fall from happening. Staff did not know of the fall until the next morning. R1 never called for assistance. The facility staff failed to report the special incident report to Community Care Licensing according to Title 22 Regulations on Reporting Requirements.

Investigation revealed the following: On 11/07/2022, Interviews were conducted with staff 1-3 (S1-S3), and residents 1-8 (R2-R8), S1-S3 and R2-R8 stated staff provided the resident with immediate assistance. S1-S3 and R2-R8 stated residents never have to wait an extended period of time for assistance. S1-S3 stated the facility was unaware of the fall and the facility is fully staffed. Staff stated they had no control over the fall and could not have prevented the incident from happening. Staff did not report or submit a special incident report to the licensing agency or the person responsible for the resident within seven days of the occurrence regarding the incident

Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D were provided to the Executive Director.