complaint·June 23, 2022

During the course of investigation, LPA L. Fontanilla did the following: 1. On 3/23/22 interviewed Executive Director 2. On 3/25/22 interviewed Staff 2 (S2) 3. On 3/28/22 interviewed Staff 3 (S3) 4. On 3/22/22, reviewed video footage of incident, needs and services plan, admission agreement, Physician’s Report Based on interviews conducted with S2 and S3, they confirmed with LPA that they were working night shift on 6/19/2020. One is assigned to stay in the hallway to redirect residents and one stays with resident in the TV room. S2 is the assigned caregiver to stay with R1 in the TV room when the incident happened. S2 and S3 confirmed with LPA that R1 was already in the TV room when they started the shift. Both S2 and S3 state that R1 is ambulatory but they would always escort R1 in going to the restroom because R1 is unsteady. S2 confirmed with LPA that S2 was in the same room with R1 during the incident but did not notice R1 get up and walk. S2 states S2 was sitting facing the wall. When LPA asked S2 the reason for facing the wall, S2 states “I don’t know why I was facing the wall.” A review of R1’s Personal Service Plan Assessment dated 06-20-2020 indicates R1 needs transfer assistance requiring 1 caregiver if needed with: 1. Dressing/Undressing (AM and PM) 2. Bathing 3. Toileting The Service Plan also indicates staff will conduct periodic checks on R1 at bedtime when resident is sleeping in the room. And that R1 needs to be monitored for balance and safety. A review of the video footage from the incident shows R1 sleeping on the chair in the TV room. (Continue on LIC9099C...) R1 woke up, looked around, pushed then pulled chair in front and tried to get up from the chair. R1 stood up and started walking but looked unsteady. R1 used chairs for support while walking towards the counter. When R1 was close to the counter, R1 lost balance, fell backwards with the chair on top of her. S2 came followed by S3. A review of R1’s medical records indicate R1 sustained closed displaced fracture of right femoral neck. R1 underwent right hip hemiarthroplasty. Based on interviews, video footage and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Sec. 1569.269(a)(10) and Sec. are being cited on the attached LIC 9099D. A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending. Exit interview was conducted. A copy of this report, appeal rights, and civil penalty were provided to Executive Director, Nancy Randhawa . Failure to provide appropriate sleeping arrangement. Failure to safeguard resident's personal belongings. On 3/25/22, LPA L. Fontanilla interviewed S2 and on 3/28/22, LPA interviewed S3. Staff interviewed confirmed with LPA that R1’s bed and personal belongings were in R1’s room when R1 was moved to the Memory Care Unit. Records reviewed indicate that on 6/19/2020, R1’s family was informed that all of R1’s belongings were moved to R1’s room in the Memory Care Unit. When interviewed by LPA on 3/25/2022, S2 states at the start of shift, R1 was already in the TV room sleeping. Staff from the previous shift told S2 that R1 refused to sleep in the room. S3 states they asked R1 to sleep in the room but R1 refused. Based on interviews conducted and records reviewed, the above allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. There is no deficiency noted. Exit interview was conducted and a copy of this report was provided to Executive Director, Nancy Randhawa .