Complaint Investigation Report

On 11/21/24 the outside party reported that there were no facility staff coming to perform prescribed reposition checks on R1 every two-three hour as prescribed by their physician. LPA obtained a picture of R1 found sleeping on the floor. The administrator confirmed that facility staff were not assisting R1 that night and ensured that it did not happen again. Per Administrator, the facility implemented a communication log for staff to document their checks. LPA was provided with logs between 10/17/23 to 11/22/23 where on different dates (10/24/23, 10/26/23,10/28/23, 10/31/23 and 11/2/23), staff reported that R1 was knocking on the back door of main building trying to come inside the facility. Based on interviews conducted with facility staff, it was revealed that night shift staff will lock the back door of the main building of the facility to block R1 from coming into the facility, and not checking on them to ensure that any possible care needs were met. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.

Regarding the allegation of staff failed to seek timely medical care for residents. Per Reporting party, on 11/2/23 Administrator notified R1’s responsible parties that R1 was out of control, reporting property damage to the flower garden and sink, but not reporting any injuries. However, based on records review of skin integrity monitoring form on 11/4/23 R1 was found around 3pm by staff with a big bruise on their right leg. On 11/7/23 at 10:40am hospice records confirmed that facility did not report any falls to them, but R1 was observed by hospice nurse with significant bruising. On 11/13/23 hospice records confirmed that the facility administrator notified them about R1’s aggressive behavior and destruction of property. Per hospice records, on 11/17/23 at 2:18pm, they were notified by an outside party that R1 was found lying on the floor and staff told them that this “has been happening a lot”. However, the facility did not notify responsible parties about it. On 11/20/23 the hospice agency scheduled R1 for x-rays to be done where results were negative for any fractures. On 11/21/23, R1 was found unconscious with a dropped jaw and staff disclosed to an outside agency that R1 sustained the injuries and decline in health because a sink fell on them weeks earlier. The reporting party expressed that it seemed like an unknown staff found R1 injured and physically moved R1 to their bed without assessing or attempting to seek medical treatment for R1. Staff tried aggressively shaking and yelling at R1 to wake them up and feed them without notifying hospice about the incident. According to hospice documents obtained indicates that on 11/22/23 hospice had a discussion with the administrator to ensure communications of R1’s condition to ensure timely hospice and medical care was provided. Therefore, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Continues on LIC9099C...