Complaint Investigation Report

C1’s injuries were consistent with a fall or some type of stress.

Per medical records, C1 has had frequent falls in the past (prior to June 22, 2021) and it was reported in record that facility staff were not sure if C1 had follow-up when falls occurred. Investigation further revealed that C1 is non-verbal, needs two staff to assist with ambulating, and utilized a wheelchair. According to multiple interviews, C1 was prone to falling. As reported, C1 would jump up while sitting down and let self-fall while on couch or while staff were changing C1 clothes. Interviews also revealed that C1 needs “a lot” of supervision and caregiver assistance with everything. Staff interviews confirmed that C1 also needs assistance with care needs including bathing, toileting, dressing, and feeding.

Although staff reported that C1 would be checked every thirty minutes or more, depending on the day C1 was having, there was no “set schedule.” Other staff reported that C1 would be checked when in bedroom, because C1 would “pretty often” attempt to get out of bed. It was also reported that there was discussion about one-on-one caregiver for C1. However, investigation did not reveal that C1 was provided with this service.

Overall, the preponderance of evidence supports that facility staff failed to ensure that C1 needs were being met. It was found that C1 was known to have frequent falls and required assistance with care needs. However, there is lack of support to identify that a care plan and/or assistance was in place and followed to meet C1 needs. As a result, on or around June 21, 2021, while at the facility, C1 sustained multiple fractures.

The above allegation is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met.

In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1548.

An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Administrator Carlito Tan..