Complaint Investigation Report
#1 Allegation: Resident sustained injury while in care
This complaint alleges that (R#1) sustained a wound on the right leg due to a dilapidated bed frame while in care at the facility.
This complaint alleges, (R#1) sustained a 6-inch skin tear on the right leg when making contact with a sharp metal piece on (R#1)’s bed frame. LPA was unable to find documented evidence or witness accounts of (R#1) sustaining an injury due to the bedframe being in disrepair. LPA found documentation stating (R#1) experienced an unwitnessed fall in (R#1)’s room at approximately 10:00 p.m., on 9/3/2022, and sustained an injury to the right leg and was bleeding. (R#1) stated the injury occurred when (R#1) was walking to the restroom in the dark and could not see what was in the way when the injury occurred. After the injury occurred (R#1) called for Staff to assist. Staff responded and found (R#1) laying on the floor and (R#1)’s right leg was bleeding. Staff then contacted 911 and EMS responded to the call in approximately (5) minutes. (R#1) was then transported to the hospital.
LPA Iniguez conducted an interview with the facility Administrator (A#1) on 3/28/24. (A#1) stated that a family member requested (R#1)’s bed frame be replaced as it was in disrepair, and this caused the injury to (R#1)’s leg. (A#1) stated she inspected (R#1)’s bed frame and found it safe for use; however, she honored the family members request to replace the bed frame. In addition, (A#1) stated that they do not know how (R#1) sustained their leg injury it was unwitnessed.
During an interview on 3/28/24 with the Maintenance Director (S#9), he stated that prior to (R#1) 's moving into the facility, he assembled and inspected (R#1)’s room furniture. He did not observe that the bed frame was in disrepair and safe for use.
On 10/25/22, LPM Lourdes Montoya conducted interviews with at the facility and found the following:
During interviews with residents (R#2-R#10), (9) out of (10) residents did not express concerns about safety in the facility.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction