Complaint Investigation Report

There is no indication the door chime was not working. Multiple staff stated the patio door alarm was operational and loud on the day of the incident. At approximately 1900 hours R1’s fall pad alarm went off and an alert was immediately sent to the cell phones for employees working that shift: S2, Staff (S3), Staff (S4), Staff (S5) and Staff (S6). S1 stated S3 was responsible for monitoring the living room area and responding to R1’s fall pad alarm. S1 stated video recordings showed S3 standing inside the living room and failed to respond to the alarm notification. S3 remained in the same position until S3 heard R1 banging on the door at approximately 1932 hours. R1 was left outside unsupervised for approximately one and a half hours. S6 stated R1 was cold to the touch indicating R1 had been outside for an extended period of time. R1 was a known fall risk and required additional supervision. R1 was not permitted to be in the patio area alone due to being a fall risk. R1 was transported to the hospital by ambulance and diagnosed with a hip fracture requiring surgery and hospitalization. Based on the Department’s observations, interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the allegation that neglect by the facility resulted in resident’s injury is substantiated. California Code of Regulations, Health and Safety Code (1569.269 (a) (6), are being cited on the attached LIC 9099D.