Inspector’s narrative
What the inspector wrote
Continued from LIC9099
Resident fell sustaining a fracture due to staff neglect
During the course of the investigation, R1’s medical records indicated that she was admitted to the hospital on August 3, 2024, due to pain in her left shoulder from a fall. She was discharged on August 7, 2024, with a diagnosis of a scapular fracture in her left shoulder. On August 11, 2024, R1 was re-admitted to the hospital for pain in her left shoulder following another fall, with the same diagnosis of scapula fracture. R1’s physician's report, dated May 21, 2024, did not indicate a diagnosis of dementia. According to R1’s Appraisal Needs and Service Plan, she requires assistance with ambulation and transfers to and from the bathroom; this was especially important at night. Interviews with R1 and staff revealed that S2 was the only staff member on duty during the overnight shift when the incidents occurred. R1 stated that S2 placed her on the commode and left her there for an extended period. S2 explained that during the time R1 was on the commode, she had to assist two other residents.
Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be
SUBSTANTIATED
. Health and Safety Code are being cited on the attached LIC809D.
A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending. A formal conference with CCLD will be scheduled at a later time
.
Continue on LIC9099C
Continued from LIC9099C
Staff left resident in soiled bedding for an extended period of time
During the course of the investigation, the Department Interviewed residents and staff. Interview with R1 stated she pressed the call button, no one came for hours. R1 stated she was left in soiled briefs, bed, and staff did not attend to her timely. During the interview, S2 stated she placed R1 on the commode while changing R1’s bedding, another resident started walking towards the front door thinking someone was ringing the doorbell. S2 went to re direct the other resident and put her back to bed. During the interview with S1, S1 stated the surveillance camera mounted in the main living area, displayed the kitchen, dining room, living room and hallway up to the table near front door. S1 reviewed the facility’s camera recordings and denied seeing anyone near the front door area, S1 did observe S2 eating, drinking, watching television and scrolling on her phone, when she watched the camera recording. S1 also stated during interview, S2 and R1 did not get along. S1 has been the mediator between the two of them over the telephone a couple of times.
Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be
SUBSTANTIATED.
California Code of Regulations, Title 22, are being cited on the attached LIC9099D.
Continued on LIC9099C
Continued from LIC9099C
Staff left resident in soiled diapers for an extended period of time
During the course of the investigation, the Department interviewed residents and staff. Interview with R1 stated she was left in soiled briefs, pressed the call button and staff did not attend to her timely. Interview with R2 indicated, when she presses the call button for assistance after having an accident in bed, staff responds between five and ten minutes. Interviews with staff S1, S2 and S3 indicated residents are checked every thirty minutes and after each meal for residents who are nonverbal and doesn’t use the call button. Residents who are verbal, will notify staff when they need assistance by telling staff or using the call button, S1 stated during interview, S2 and R1 did not get along. S1 has been the mediator between the two of them over the telephone a couple of times. Interview with S2 stated she placed R1 on the commode while changing R1’s bedding, another resident started walking towards the front door thinking someone was ringing the doorbell. During the interview with S1, S1 stated the surveillance camera mounted in the main living area, displayed the kitchen, dining room, living room and hallway up to the table near front door S1 reviewed the facility’s camera recordings and denied seeing anyone near the front door area,
Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be
SUBSTANTIATED.
California Code of Regulations, Title 22, are being cited on the attached LIC9099D.
Exit interview conducted. A copy of this report and appeal rights provided.
Continued from LIC9099C
Staff do not treat resident with dignity and respect
During the course of the investigation, the Department interviewed residents and staff. Interview with R1 indicated some of the staff were respectful, and there were some not so much. Interviews with R2, S1, S2 and S3 indicated staff treats residents with respect and dignity and has not witnessed any disrespect towards the residents in care. S1 also, indicated treating residents with respect is one of the facility’s requirements before hire and is also part of staff’s onboard training.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are
UNSUBSTANTIATED
.
Staff did not provide resident's authorized representative with resident's records
During the course of the investigation, the Department interviewed Administrator (ADM). ADM stated during interview, facility provides residents record information to family members, conservator or responsible person (RP), as long as the documents requested does not have any other resident’s information on the documents. ADM provided LPA with emails to R1’s family members of requested documents/records, LPA observed during records review the requested documents were submitted to R1’s family members.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are
UNSUBSTANTIATED
.
No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.
