Complaint Investigation Report

Staff interviews revealed R1 had three (3) unwitnessed falls on 9/11/22 at 9:30pm, 11:30pm, and into 9/12/22 at 1:30am. Staff described the first two (2) falls as “slips”. Staff interviews revealed after the first fall , R1 was found by Staff #1 (S1) in a seated position on the floor. S1 had called Staff #2 (S2) to assist R1 off the floor. After the second fall at 11:30pm, again R1 was found in a seated position and assisted by S1 and S2 off the floor. Staff stated R1 reported they were okay after the first two (2) falls and stated R1 was given an assessment to determine if there were any significant injuries or bruises. Interviews revealed that staff reported none were found. Written document to corroborate this statement was not provided.

R1 fell a third time 9/12/22 at 1:30am. Staff reported R1 had one of their legs bent, and in an “unnatural position”. S1 contacted Staff #3 (S3) for assistance. Staff interviews revealed R1 expressed being in significant pain, and staff called 911. Staff interviews revealed the measures taken to increase supervision of R1, were that R1 had a pendant they could press if staff were needed.

A facility document titled “Falls Addendum Service Plan and Intervention Protocol”, dated 07/02/2022 signed by R1’s responsible party and the licensee. Item #5 on the documents reads in part, “Placement of restless resident who is in danger of falling in constant view of caregiver by not leaving him/her unattended and out of eyesight.”

Staff interviews revealed the measures taken to increase supervision of R1, were that R1 had a pendant they could press if staff were needed. The interview did not reveal any further steps taken to increase supervision of R1. Therefore, based on the above, the allegation is substantiated.

An immediate civil penalty of $500 is being assessed. In accordance with Health and Safety Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.