Complaint Investigation Report

Interdisciplinary Plan of Care Revision dated 7/15/22 indicates doctor’s order was for a three-person assist. R1 sustained injury on 7/17/22 while being transferred from Hoyer lift to wheelchair by two-person assist. Staff members did not follow R1’s medical orders for a three-person assist. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated by the California Code of Regulations, Title 22, Health and Safety Code section 1569.2(c). Per disclosures made during interviews and records obtained by LPA it was determined staff members did not follow resident's medical orders dated 7/15/22 and R1 sustained an injury while being transferred from Hoyer Lift to wheelchair.

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.