Complaint Investigation Report

Per UIR R1’s lab results were received on 09/01/21 stating that R1’s plateles were low due to her diagnosis of Pancytopenia. Per Huntington Beach Hospital lab results dated 09/01/21 the White Blood Cell (WBC) and the Red Blood Cell (RBC) value for R1 were below Reference Range.

During the course of the complaint The Department conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Five of seven individuals interviewed denied the allegation. As for the remaining two individuals, one individual confirmed the allegation and the other did not return the call. Records reviewed included the Santa Avila Care Villa NOC Shift Notes dated 08/07/21-08/26/21 for R1. Per NOC Shift Notes R1 was monitored throughout the night as R1 often slides off their bed and dives into the floor. It was reported via interviews that on 09/01/21 R1 was noted to be pale and appeared tired. Per UIR R1 was transported to the Emergency Room on the evening of 09/01/21. During the course of the interviews AD stated that the symptoms of Pancytopenia can include bleeding, easy bruising, fatigue, shortness of breath and weakness. Records reviewed included Appraisal/Needs and Services Plan dated 08/01/21 for R1. Per Appraisal/Needs and Services Plan R1 wears a protective helmet and knee pads due to ataxia and history of falls…has no safety awareness when agitated and on behavior breakdown. It was reported via interviews by R1’s Physician that R1 has been diagnosed with Idiopathic Thrombocytopenic Purpura (ITP). The Mayo Clinic defines ITP as unusually low levels of platelets, the cells that help blood cloth. Per R1’s Physician the symptoms of ITP are easy bruising, extreme bleeding, bleeding from gums and nose, blood in urine and stools and unusually heavy menstrual flow. It was reported via interviews that it is common to see bruises for R1 in different stages of healing and that staff will document bruising on body check forms.

Although resident sustained bruises while in care the investigation could not conclude if the bruising was due to neglect. It remains unclear at this time if the bruising was as a result of the client’s self-injured behavior or if it was caused by facility staff.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Therefore, the allegations have been deemed to be UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred.

LPA Ramirez conducted an exit interview with AD Alipio, and a copy of this report was provided to the facility.