Complaint Investigation Report

Allegation: Lack of supervision resulting in injury to resident in care.

Resident had an unwitnessed fall after rounds were done.

During file review, the department observed a Special Incident Report (SIR) was faxed to Community Care Licensing on 11/02/2024, regarding an incident that occurred on 10/28/2024 in regard to R1. The SIR stated R1 was observed on the floor with broken glass around them and bleeding was noted. The department received and reviewed R1’s Service Plan Details dated on 10/24/24 that indicates for Mobility/Ambulation, Escorts, and Transferring resident R1 may require prompts/cues for safety, does not require hands on assistance. Additionally, it indicates resident R1 has experienced a fall on 07/30/24 and was observed on the floor on 08/25/2024 resulting in interventions being put in place to minimize fall risk and decrease injury including Mobility program/physical therapy and hip savers. The department received and reviewed a copy of R1’s hospital discharge paperwork from Torrance Memorial Medical Center that states R1 was seen for an unwitnessed fall and abrasions were observed on R1’s legs.

During interviews with Staff S1-S9, were asked if there is enough staff on each shift to provide proper supervision, nine (9) out of nine (9) stated there is enough staff on each shift for proper supervision.

During interviews with Residents R2-R6, were asked if there are enough staff on each shift to provide supervision to residents, five (5) out of five (5) stated there is enough staff on each shift to provide proper supervision. Additionally, during interviews Residents R2-R6 were asked if they have sustained injuries due to lack of supervision, five (5) out of five (5) stated they have not sustained injuries due to