Complaint Investigation Report

On October 26, 2019 at approximately 0600 R1 was observed sitting in a chair by the nurses’ station with a blood face and injuries to the lip and eye. R1 was sent to the hospital and was diagnosed with a superficial laceration of the right upper lip with minimal swelling, bilateral lower extremity trace edema, multiple superficial skin tears in the lower extremities, multiple bruises, closed head contusion, closed fracture of multiple ribs of right side, initial encounter and hemopneumothorax on right side. Staff interviews did not provide evidence as to how R1 sustained the injuries. Staff indicated R1 was checked on during the overnight shift, however, no one observed R1 fall, nor did anyone observe how R1 obtained the injuries. Staff interviews indicated residents are to be checked on every two hours, however the investigation did not provide sufficient evidence to show R1 was checked on every two hours on the night of October 26, 2019. Based on the Departments investigation there is corroborating evidence to support the allegation that R1 sustained multiple injuries due to neglect, therefore this allegation is substantiated.

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 § 1569.49.

An exit interview was conducted and a copy of this report, along with LIC 9099D and appeal rights were provided to Sheila Fike.