Complaint Investigation Report

Interviews with staff including S3, S1, S5 and S7 revealed consistent statements of R1's decline in her ability to be stable and walk. S1, S5 and S7 detailed that R1 had three to four falls that occurred within the last six months of R1 living at the facility. S3, S1, S5 and S7 denied knowing about a fall prevention plan for R1. All of the staff agreed that the alert pendants were not reliable and do not always work.

Additionally, regarding reporting requirements, A2 and A1 both provided statements to the department they were not contacted regarding R1's latest fall and hospitalization. These statements have been corroborated by R2 who provided statements that A2 was not aware of R1's fall and hospitalization or absence from the facility. Staff interviews were unable to corroborate a staff actually contacted an emergency contact and the facility was unable to provide any evidence of contact with emergency contacts.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision, Reporting requirements and Other is substantiated.

The following deficiencies are cited per California Code of Regulations, TITLE 22. Due to the identified violation resulting in a resident injury an immediate civil penalty is issued and the department will evaluate the circumstances of the violation for additional civil penalties.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.