Complaint Investigation Report

The second allegation indicates residents are locked in an area of the facility. Interviews with staff, Hospice Nurse and CALFIRE Beaumont staff revealed that residents are not locked in an area of the facility and no incidents occurred that they witnessed a resident locked in an area of the facility.

The third allegation indicates resident sustained unexplained injury while in care. Interviews and documents review revealed that R1 had an abrasion/skin tear on left hand due to R1's reported falls from getting up of bed with bedrail. S1 reported that they are reporting all incidents and falls to R1's Hospice and R1's medically assessed each time by the Hospice Nurse. LPA Brown reviewed Hospice Care Notes and LPA Brown observed that R1's left hand had an abrasion/skin tear was noted and reported due to R1's fall from getting up of bed with bedrail.

The fourth allegation indicates staff did not seek medical attention in a timely manner. Interviews and documents review revealed the facility's reporting all R1's incidents to R1's Hospice and either a Hospice Nurse will come out to the facility to medically assess R1 or the facility will call 911 if instructed by R1's Hospice. Hospice Nurse reported that the facility always report to them and they give instruction to facility staff of what to do and no incident occurred at the facility that staff did not seek medical attention for R1 in a timely manner. Also, LPA Brown reviewed Hospice Care notes and it indicated that during the incident last 10/10/2021, the Hospice staff did not advise the facility to call for non-emergency services and the facility waited for Hospice Nurse to medically assess R1.

Based on interviews and records review, the allegation resident sustained multiple falls while in care (Allegation #1), residents are locked in an area of the facility (Allegation #2), resident sustained unexplained injury while in care (Allegation #3), staff did not seek medical attention in a timely manner (Allegation #4) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Administrator Caroline Armstrong.