complaint·December 28, 2022

Continued from LIC9099. the facility never reported the fall. The Reporting Party (RP) stated during interview that the facility never called 9-1-1 after the fall. The RP also stated that RP called R1’s doctor and had a Mobil x-ray conducted. The x-ray showed that R1 had a broken femur, and the facility did not call 9-1-1 until 08:30PM. During record review of Alta Bates Summit-Merritt discharge summary notes dated 07/02/2020, notes indicate that R1 was x-rayed on 6/27/2020 at 11:03PM and was seen/examined on 06/28/2020. Even though medical attention was given to R1 it was not done in a timely manner, therefore, based on the investigation the allegation is deemed Substantiated. Based on LPA interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided. Continued from LIC9099. R1 on the floor. Documentation for R1 also indicates, R1 sustained approximately five additional falls despite having various one-to-one private caregivers. Staff stated during interviews that memory care clients are checked every two hours. Staff that were interviewed all stated R1 was a wanderer and would often forget to use her walker or would leave it in multiple places. Staff also stated during interviews that memory care clients are checked every two hours. Reporting Party (RP) stated that on 6/27/2020 R1 was found on the floor by staff at approximately 3:20AM. (RP) contacted the on-call doctor prior to R1 being transported to the Emergency Department (ED) and x-rays showed R1 sustained a left femur fracture. During the course of the investigation, including file review, the Department observed that after R1 transitioned to the memory care unit on 5/30/2020, R1 continued to sustain injuries from multiple falls. Record review indicated that it was documented in Hospice Care’s initial assessment of R1 that R1 was never to be left unsupervised. Records also indicated that the family provided a one-to-one caregiver. The caregiver along with facility staff indicates R1 was not left unsupervised. Review of R1’s unusual incident reports that occurred between 5/24/2020 to 6/15/2020, it was documented and noted that medical treatment was not necessary as R1 sustained bruising and did not complain of any pain. Review of the facility’s unusual incident reports and staff charting indicates that R1 had a history of falls. Continued on LIC9099C. Continued from LIC9099C. Staff that were interviewed all stated R1 was a wanderer. Record review and interviews indicated that on 6/17/2020 R1 wandered into another resident’s room where she was found on the floor by the RP. R1’s one-on-one private companion was cancelled on 6/7/2020 and restarted on 6/22/2020, thus R1 did not have a one-on-one companion at the time of the incident. Record review indicated that staff responded when they heard Resident 2 (RP 2) screaming loudly once, therefore staff was in the general area and was able to respond in a timely manner at the time of the incident. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of report was given .