Complaint Investigation Report

Per review of R1's records, R1 was an identified fall risk and required the use of an assistive mobility device. According to R1's Needs & Services Plan, staff were to verbally remind R1 to utilize their assistive device or to bring it to R1 if observed not to be in use. Per file review, R1 has a documented history of seating themselves on the floor, which was also a behavior of R1's corroborated by staff during interviews. However, records review revealed that over the course of 20 consecutive months, R1 experienced 28 falls with 8 resulting in hospitalization. While 9 out of 28 were instances of R1 being found self-seated on the floor with no apparent injuries, the remaining 19 were not, and review of incident reports note that R1's assitive device was not present for a majority of R1's falls. All staff interviewed recalled R1, with some noting the R1 needed reminders to use their assistive device, but revealed conflicting beliefs of if R1 was indeed a fall risk --despite R1 being labeled one in their records. Two (2) staff interviews noted that R1 tended to be non-compliant with utilizing their assitive device. Residents and outside sources interviewed revealed no concerns regarding falls or ambulation in regards to resident needs.

Based on LPA's review of records, interviews with staff and outside sources, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. An exit interview was conducted with Associate Executive Director Spence to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.