Complaint Investigation Report

Review of R1’s medical assessment records dated March 2, 2023, revealed that R1 had a diagnosis of Alzheimer’s disease and dementia, was confused and disorientated, had limited ability to communicate, and could feed themself with set up assistance but required staff assistance for all other activities of daily living (ADLs). R1 was also non-ambulatory and had a secondary diagnosis of falls. Review of R1’s needs and services plan dated September 3, 2024, revealed that R1 required a wheelchair for ambulation and mobility. The Department attempted to interview R1 but R1 was unable to be used a reliable historian to aid in this investigation due to their baseline memory loss.

Record review and interviews revealed that R1 was a high fall risk and had a history of witnessed and unwitnessed falls. Interviews with staff and record reviewed revealed that on January 18, 2025, R1 was being wheeled by Staff #1 (S1) to their bedroom from the common area. When R1 and S1 arrived at R1’s bedroom door, S1 bent over to open R1’s door using a key that was located around their neck. While doing so, R1 fell forward out of their wheelchair and hit their head on the ground. Interviews with staff and outside sources revealed that R1 had a history of bending over in their wheelchair. Interviews with staff and outside sources revealed the concern of R1 bending in their wheelchair could have been mitigated with a high back wheelchair. However, there are conflicting statements as to why the high back wheelchair was not obtained. On January 23, 2025, upon discharge from the hospital with hospice services, R1 obtained a high back wheelchair. Review of R1’s medical records revealed that R1 required nine sutures as a result of the fall.

Record review revealed R1 suffered two unwitnessed falls prior to the fall on January 18, 2025. On February 1, 2023, and November 29, 2024, R1 was found on the floor by their bed. Records review of facility progress notes revealed that staff observed R1’s bed rails not in place after the fall on November 29, 2024. Interviews with staff and outside sources corroborated that R1’s bed rails were not secured. The bed rails were reported to be faulty.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of evidence exists to support the allegations that neglect/lack of supervision resulted in laceration and residents bed rails were in disrepair. An immediate $500 civil penalty was assessed and is noted on the LIC421IM. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. Two deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A plan of correction was jointly formulated and an exit interview was conducted with Executive McCoy, to whom a copy of this report, LIC 9099-C, LIC 9099-D, LIC421IM and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.