Complaint Investigation Report

Per outside interviews, their LIC602 Physician’s Report, and their Care and Service Plan, R1 was in an early stage of cognitive impairment but still “able to follow instructions” and “able to communicate [their] needs.” CCLD interviewed R1 and verified they were a credible witness. R1 was alert and oriented to self, others, place, and time. R1 was articulate and self-aware, able to describe their current physical and cognitive condition, their likes and dislikes, and their life story. R1 affirmed knowing and remembering who S1 was. R1 said S1 never touched their breasts or any other part of their body in a sexual manner, nor did they tell anyone such. R1 said their breasts still hurt, six months after they moved out of the facility, concluding, “I think I have breast cancer.”

S1 also denied the allegation. S1 said they were administrative staff and thus not hands-on with any aspect of R1’s personal care. Interviews of multiple facility caregivers and review of the facility’s care task logs corroborate S1 did not personally bathe, dress, or toilet R1; caregivers instead completed these tasks. The complainant admitted there were no witnesses to the alleged incident with R1. All staff interviewed said they never saw S1 inappropriately touch R1 or any other resident. The San Diego County Long Term Care Ombudsman’s Office (LTCOP) reviewed the alleged incident, advising CCLD that they found no evidence of wrongdoing.

CCLD observed the bedside device described by the complainant, determining it was a pressure-activated bedside alarm/alert mat, a tool not expressly prohibited by California Code of Regulations or California Health and Safety Code. According to a March 2019 study titled “Alarming and/or Alert Device Effectiveness in Reducing Falls in Long-Term Care (LTC) Facilities? A Systematic Review,” published by the National Institutes of Health ( www.nih.gov ), alert devices “can assist in the care and safety of nursing facility residents…when used as one piece of a comprehensive care plan…” and “can be quite effective devices in ensuring resident safety.”