Complaint Investigation Report

435202041-2-17-2024-26-AS-KHOS-D36K93-20240308064137

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

04/10/2023 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 26-AS-20230410165453

Lack of staff supervision resulting in serious injury

On 2/16/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator Armie Tancinco. LPA explained the purpose of the visit.

Regarding the allegation of lack of staff supervision resulting in serious injury, the reporting party (RP) stated that the resident (R1) was admitted to the ER but there was no fall or traumatic incident reported that would have caused the fracture. RP stated that the injuries were more likely the result of lack of supervision and assessment rather than abuse.

Based on record reviews R1 has diagnosis of bone issues. R1 was also admitted to the hospital on 02/08/23 & 3/26/23. On both occasions, was assessed by staff when admitted back to facility, as having a swollen left arm due to possible IV insertion. On the progress notes from 3/31/2023, morning & afternoon shifts, no unusual changes in R1s vital signs and appearance were noted. At around 1:30 AM, 4/1/23, the RN went to check R1’s pulse oximeter reading and noted that the left arm was swollen as compared to the right. Facility staff has annual training for handling patients/residents. There were also no reports of resident falling or hitting something. R1’s bedrail also has pads.

Based on interviews and record reviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

The report was reviewed, and a copy is provided.