Complaint Investigation Report

547203298-7-26-2022-24-AS-MHON-CGYMEY-20220804093332

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

04/14/2022 and conducted by Evaluator Melinda Medina

COMPLAINT CONTROL NUMBER: 24-AS-20220414095227

Resident was neglected while in care resulting in resident falling and sustaining a fracture

During the investigation, the Department reviewed R1’s records and interviewed staff. Based on interviews and records review, R1 had several ground level falls on 4/9/22 however staff did not seek medical attention until the last fall when R1 fell face first into the nightstand and was observed to be wedged between the nightstand and the bed. Staff called emergency medical services and R1 was transferred to the hospital where R1 was admitted and diagnosed in part with a left proximal humeral fracture. R1 remained in the hospital until discharged on 4/15/22. The preponderance of evidence standard has been met therefore the allegation that resident was neglected while in care resulting in resident falling and sustaining a fracture is substantiated.

Deficiency for violation of Title 22, Section 87468.2(a)(4) cited in the attached 9099D.

An immediate civil penalty of $500 is assessed and the issuance of additional civil penalties is currently under review. The details of the additional civil penalties will be outlined in a future report to the facility if needed.

Appeal rights provided. Exit interview conducted.