Complaint Investigation Report

At approximately 03:10pm the LPA conducted a physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings.

On 04/01/2025, at approximately 10:30am, Investigator Real conducted interviews with R1’s resident representative; on 04/17/2025, from approximately 11:30am to 2:00pm, with R1, staff, and residents; on 06/13/2025, at approximately 12:25pm, with the Administrator; on 06/17/2025, at approximately 12:30pm, with the overnight staff; and on 07/01/2025, at approximately 12:50pm, with R1’s resident representative. In addition, Investigator Real reviewed Los Robles Regional Medical Center medical records and facility file documents related to the investigation.

According to the facility file documents reviewed, R1 was admitted to the facility on 06/15/2024. R1 had a history of falls and was considered a fall risk. R1’s Appraisal Needs and Services Plan, updated 12/27/2024, noted confusion and agitation at night, with R1 attempting to walk without supervision. The plan noted safety measures were put in place and staff encouraged R1 to use the call button at night.

A review of the Unusual Incident/Injury Report related to R1’s fall on 02/07/2025 revealed the overnight staff checked on R1 at 12:26am and at that time R1 was in bed. At 12:40am the staff heard the safety mat alarm and saw R1 on the floor in R1’s room with leg pain. R1 did not request assistance prior to getting out of bed. The Administrator was notified and 911 was called. Paramedics transported R1 to the hospital.

A review of the Los Robles Regional Medical Center medical records revealed R1 was admitted to the hospital on 02/07/2025 with a diagnosis of femur fracture. Surgical procedure was performed to repair the fracture. R1 was discharged from the hospital on 02/14/2025.

The Department’s investigation revealed the facility provided a sufficient level of care and supervision for R1. R1, who suffered from dementia, did not have 24/7, one on one supervision. R1 wore a call button alarm that R1 could use to contact facility employees when R1 wanted to get out of bed and was consistently reminded by staff to use the alarm so that staff could assist R1 out of bed.