Complaint Investigation Report

It was reported that Resident #1 (R1), sustained an injury while in care, as it was alleged, that Staff #1 (S1), used a gait belt on R1, which resulted in R1 sustaining “broken ribs”. The Reporting Party (RP) was anonymous, and no further details were provided. Interviews and records review reflected that R1 would only use a gait belt during physical therapy sessions with their therapist. Interviews conducted with eight (8) staff members further revealed that all have not observed any staff use a gait belt to assist with ambulation for any resident at this time.

Additionally, similar allegations pertaining to this incident were investigated by the Department previously (Complaint Control # 29-AS-20200908142229). Based on the investigation, R1 had healing fractures on R1’s rib cage. During that investigation it was revealed R1 has a health history including osteoporosis, edema and unsteady gait. R1 ambulated independently. On 09/06/2020, R1 got up to use the restroom and began to fall. Staff intervened, lowering R1 to the ground. Facility staff called 9-1-1, and paramedics came and took R1 for treatment at the hospital. Although facility staff informed paramedics of the fall, this information was not immediately relayed to hospital staff. During R1’s hospitalization on 09/06/2020, R1 was solely treated for edema and subsequently discharged on the same day. On 09/07/2020, facility staff noticed R1, who is non-verbal, to be in pain and unable to stand. Staff immediately called 9-1-1 and R1 was taken to the hospital, where R1 was diagnosed with a broken femur. Medical professionals interviewed indicated that the injuries R1 sustained are consistent with a fall. Los Angeles Police Department (LAPD) investigated the incident and indicated R1’s injuries are consistent with a fall. Based on information obtained over the course of the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “R1 sustained an injury while in care” has been deemed Unsubstantiated at this time.

It was reported that staff did not seek medical care for R1 in a timely manner, as it was alleged that R1 became sick, but was not given timely medical attention. RP is anonymous; therefore, LPA was unable to confirm the date and time when R1 became sick and did not receive timely medical attention. However, interviews and records review revealed on 10/16/2021, an Unusual/Serious Incident Report (SIR) was received by the department, which indicated R1 displayed low oxygen levels and 9-1-1 was called. R1 was later diagnosed with Pneumonia. LPA’s interview with eight (8) staff revealed all staff have observed that if any resident displays any cold or flu like symptom, they check their vitals, inform Administrator then contact medical services, if necessary.