complaint·December 12, 2023

LPA interviewed 7 staff S#1-S#7 including administrator. On 9/25/22 two staff S4 and S8 were attempting to change resident when resident fell to the ground and hit R14 face on R14 wheelchair footrest that were removed from R14 chair and were by the beside. Administrator stated she was not at facility when incident occurred and does not know how R14 got injured. S4 who was in the room when the incident happened stated she was helping S8 to get the R14 to bed and R14 was very agitated and didn’t want anyone to touch R14. S4 and S8 were able to get R14 in bed from wheelchair and R14 continues to fight with staff and yelling at them to not touch R14. S4 stated R14 struck S8 after we changed R14, and I went to get a dress from R14 closet and had my back turned and heard S8 yell and turned around to see R14 on the floor and R14 had thinks R14 struck R14 face on the wheelchair footrest. S4 stated she did her report and does not recall if R14 went to hospital that day. Supervisor S2 stated R14 was in chair and fighting the staff while they attempted to change R14. S2 stated R14 was in chair when R14 fell and that she may have hit the wheelchair footrest on the floor. Supervisor S3 did not remember what occurred. S5 (temporary Administrator) stated she didn’t know what happened. S5 stated that daughter was told about incident but not the extent of the injuries and did not recall the date. S6 stated she did not know anything about the incident. LPA attempted to contact S8 on more than 3 occasions and was unsuccessful. S8 is no longer employed at the facility. There were several differing explanations of how the bruises and injuries had occurred but none that fully explained what happened. Resident 14 was hurt, staff failed to properly assess R14 injuries, seek medical attention and did not send R14 to hospital until the next day. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated. Allegation: Staff denied authorized representatives to access resident records. It is alleged that both the resident’s daughter and Ombudsman asked for residents records and were denied access to the records by facility. S6 admitted to LPA denying access to incident reports to Ombudsmen explaining that she was following legal advice from facility attorney. The daughter of R14 sent several emails requesting R14 medical record beginning on Oct 4 th , 2022, and the facility did not provide them within 24 hours as required by regulations. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated. Allegation: Staff did not report incident to appropriate parties. It is alleged that the facility failed to report two incidents to appropriate parties. The facility failed to report the incidents to the Ombudsman when the Ombudsman requested incident reports. The Ombudsman had received authorization to act on behalf of resident and should have been able to review and obtain copies of the incident reports dated 09/25/2022 and 09/26/2022. Finally, on 10/25/2022 the two incident reports were emailed to Ombudsman Tam dated 09/25/2022 and 09/26/2022. LPA noted that the SIR from incident on 09/26/2022 was dated on 09/25/2022. CCL has a record of SIR from 09/25/2022 but no internal record that SIR from 09/26/2022 was reported to CCL. Facility could not provide proof that SIR dated 09/26/2022 was faxed over. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated. Based on LPA's observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D. An exit interview was conducted with Supervisor Anne Graves and a copy of the report and appeal rights were provided.