complaint·December 19, 2022

Staff did not safeguard resident’s incident report - SUBSTANTIATED LPA reviewed 3 internal incident reports dated 10/02/2022,10/03/22, and 10/07/2022. In the reports dated 10/02/2022 and 10/03/2022 R1 was found on the floor next to their recliner. The report dated 10/07/2022 did not specify where R1 was found other than “on the floor.” None of these unwitnessed falls were reported to licensing. During staff interviews 1 of 6 staff stated that the incidents were reported to the manager. 5 staff stated they did not know if the incident was reported. Administrator stated If residents are OK with no injuries and they don’t go to the hospital then we just do an internal report. We have a report on 10/03/22 that R1 fell out of their recliner. The family said EMTs were not needed so R1 was not sent out. Any time the EMTs assess R1 and say R1 doesn’t need to go out to the hospital we don’t report it. Staff hand fills out a report, it is given to me, and then I decide if it needs to be reported to CCLD. They are trained on the process. It was determined that staff are reporting incidents via internal report to the administrator. If the resident does not go out to the hospital the report is not being sent to CCLD. The facility needs improvement on their incident reporting process and the requirement to report to CCLD therefore this allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Melissa Morales. Page 2 Resident fell due to staff not making sure resident was in bed properly - UNSUBSTANTIATED LPA reviewed 3 internal incident reports dated 10/02/2022,10/03/22, and 10/07/2022. In the reports dated 10/02/2022 and 10/03/2022 R1 was found on the floor next to their recliner. The report dated 10/07/2022 did not specify where R1 was found other than “on the floor.” There were no injuries reported on these incident reports. Review of R1’s Level of Care form dated 02/07/2022 states under the Mobility intervention section that R1 needs occasional in-room supervision. 9 of 9 residents interviewed stated they had not heard of a resident falling out of their bed. During staff interviews 3 of 6 staff stated they had heard that R1 had fallen out of their recliner, not their bed. No staff interviewed had witnessed R1 fall out of their recliner or bed. Administrator stated R1 has onset dementia and can ambulate independently. There was a period where R1 had a UTI and started talking and moving. R1 was getting up for no reason. When going to bed R1 sits on the side of the bed and turns to their side which puts them in the middle of the bed. R1 is not left hanging off the bed and is not bed bound. R1 doesn’t get up without staff guidance but when R1 had a UTI they became active. It was determined that R1 was diagnosed with a UTI which made R1 more active than usual and the administrator and staff were aware that R1 was more active. As a result, on 10/02/2022 and 10/03.2022 R1 fell out of their recliner, and on 10/07/2022 R1 was found on the floor. There is no evidence that R1 fell out of their bed but R1 did fall out of their recliner twice and was found on the floor once. LPA recommends that the facility re-evaluate R1’s mobility supervision needs. This allegation is unsubstantiated. Page 3 Staff did not assist resident in a timely manner - UNSUBSTANTIATED During staff interviews 5 of 6 staff stated they didn’t know how long it took staff to respond to R1 after they fell. 1 staff stated they completed their rounds at 10:00 PM and R1 was found on the floor at 10:30 PM. It is unknown what time R1 fell. Administrator stated We check the residents every 2 hours but R1 keeps their door open and you can see them from the door. Staff puts R1 to bed about 9:00 PM and then checks on R1 every 2 hours. Administrator stated that R1 does wear a fall detector pendant. It was determined that staff completed nightly rounds at 10:00 PM and checked R1 at 10:30 PM which is an acceptable amount of time between checks. This allegation is unsubstantiated. Staff left residents in soiled diapers for an extended period of time - UNSUBSTANTIATED 8 of 9 residents stated they had not heard of or experienced staff leaving residents in soiled briefs. 1 resident had trouble hearing the question during their interview and did not answer. During staff interviews 3 of 6 staff stated that residents were not left in soiled diapers during their specific shift. 2 of 6 staff stated they had heard that staff left residents in soiled diapers for an extended period of time but had not witnessed this. 1 staff stated they had never heard anything about this. Administrator stated We had a resident who didn’t like to be changed by male staff and would wait for a female staff. It’s her right to not have a male change her if she doesn’t want to. It was determined that staff are changing resident’s soiled briefs in an acceptable amount of time and residents are not waiting an extended period of time to be changed. This allegation is unsubstantiated. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Melissa Morales.