Complaint Investigation Report

Allegation 1 : Resident sustained unexplained fractures while in care.

It is alleged that Resident #1 (R1) sustained unexplained fractures while in care. Reporting Party (RP) reported R1 was admitted to Torrance Memorial Hospital on 9/16/2020 and the x-ray result shows R1 had two broken ribs. IB Investigator Kujawa interviewed the Administrator (S1) and a Witness: R1’s family (W1). Investigator Kujawa was unsuccessful in his attempts to interview the two caregivers (S2 & S3) who were present during the incident. During the attempts by Investigator Kujawa to interview the two (2) caregivers, S2 was out of the country and S3 was no longer employed with the facility. Investigator Kujawa attempted to interview R1 (the victim); but due to medical conditions, a proper interview was not accomplished. Investigator’s interview with S1 revealed S2 witnessed R1 slide/fall out of the chair and onto the floor. S2 called S3 to assist with picking up R1 off the floor. S2 and S3 asked R1 if the resident had any pain and R1 denied pain. S1 stated both caregivers (S2 and S3) examined R1 and found no evidence of pain or injury. S1 admitted that S2 and S3 are not medical professionals and do not have medical training; but, S1 revealed that R1 was not taken to the doctor for an examination. S1 claims they did not know about R1’s fall until R1’s son notified S1 (by telephone) that R1 had suffered two (2) fractured ribs. Interview conducted of S3 by RA Ceniceros (via landline) on 08/17/23 corroborated that facility staff did not witness R1 slip and fall on 09/12/20.

Based on records review, the hospital discharge summary documented that R1 was admitted to the hospital on 9/16/2020 at 13:40 hours with a diagnosis of “Fall” and “Multiple fractures of ribs of the right side”. R1’s Computed Tomography (CT) Chest Scan revealed right-sided fractures of the eighth and ninth ribs. R1 was discharged from the hospital on 09/18/2020 without any complaints. Based on records review and interviews, there is no sufficient evidence to corroborate the above-mentioned allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation of Neglect/Lack of Supervision: “Resident sustained unexplained fractures while in care” is found to be UNSUBSTANTIATED.

Evaluation Report Continues on LIC 9099C...