Complaint Investigation Report

Investigator Ferris conducted interviews on 12/08/2022 with the Executive Director/Administrator and residents; on 12/19/2022, with R1’s resident representatives and staff; and on 01/03/2023, with the Director of Assisted Living and staff. In addition, the investigator reviewed Sherman Oaks Hospital medical records, Gem Home Health records, and facility file documents related to R1.

R1’s Physician Report, dated 05/17/2022, stated R1 was diagnosed with mild cognitive impairment, history of skin breakdown, able to follow directions, communicate needs, requires assistance with transfers and is non-ambulatory. According to R1’s resident appraisal, dated 06/13/2022, R1 required assistance with transfers and bathing, has limitations with ambulation, uses a wheelchair, and is non-ambulatory. Skin integrity was listed as a stage 2 of left side of buttock currently on home health for treatment. The Assessment and Service Plan listed R1’s move in date as 06/13/2022 and documented that R1 had a healed wound in sacrum, uses home health aide for healed wound to prevent skin breakdown.

The investigation revealed that on 08/08/2022, R1 experienced a fall during their shower. The nurse asked Staff #1 (S1) to assist with the shower. R1 did not want a shower but the nurse and S1 encouraged R1 to shower. S1 assisted R1 with the shower using a shower chair. Near the end of the shower, S1 asked R1 to stand up and hold onto the shower bars so S1 could rinse off the soap from R1’s body. R1 stood up and held onto the shower bars when R1 slipped and fell on their buttocks. R1 yelled “I broke my hip!”. The nurse was present in the bathroom the entire time and witnessed the incident. R1 was able to get up with assistance of staff and completed their shower.

At the time of the incident, R1 denied paramedic assessment, complained of back pain, describing the pain as “low” (3 out of 10) on the pain scale, and requested Tylenol. The Director of Assisted Living was notified and advised staff to monitor R1 for any changes in condition. R1’s primary care physician and resident representatives were notified of R1’s fall.