Complaint Investigation Report

Interviews with facility staff revealed that facility staff unanimously could not state to the LPA how the resident received the injury almost two years ago to the date of the initial complaint, who treated it at the time, and whether or not it was reported to the POA. All interviewed staff agreed that the preferences of reporting incident reports and other reportable events to the POA for R1 were to be communicated by phone when the POA was not at the facility visiting R1. Facility staff agreed that most reports were communicated verbally when the POA would visit on a daily basis.

Records Review revealed that the staff were aware of the injury. Care notes from the facility dated on 07/11/2024 at 1:56 AM stated, "Resident has a skin tear on their left shin. Medtech cleaned the area and put on a large band aid." In an email sent directly to facility staff about R1's care from the POA, it was stated that they were never notified through phone that R1 received the injury on their lower left extremity nor was the POA emailed a response by facility staff. In several other emails sent to the LPA by the POA of their conversations with the facility, it was stated that the POA visited R1 on a daily basis almost without fail and received verbal updates from staff in addition to phone calls.

The regulation of CCR Title 22 87211 Reporting requirements states that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D); (B) Serious injury as determined by the attending physician and occurring while the resident is under facility supervision. Welfare and Institutions Code Section 15610.67 provides: “Serious bodily injury” means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation. The skin tear injury that R1 sustained does not fall under this definition and is not considered a serious injury and was not required by licensing requirements to be reported to CCLD offices or to the representative.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.