complaint·September 12, 2022

Rather than pulling a resident by their forearms, staff are instructed to assist with a transfer by placing their arms under R1’s armpits for a gentle assist. R1 claimed that this was the first time this had happened and believed it was accidental. Interviews confirmed that R1 reported this occurrence to staff; however, R1 did not identify the specific staff whom performed the improper transfer. Additional interviews confirmed that the bruising was reported to Director of Wellness and to the Director of Resident Care Services on 8/20/2022. It was reported that once staff received word of this incident, staff checked in with R1. Whereas it was reported that the facility is unaware as to whom pulled R1 by the arms, there was no additional follow up, investigation, or training conducted with care staff. Interviews and records review indicated that R1 was prescribed Eliquis, which according to the Mayo Clinic, can make a person more susceptible to bruising as it is a blood thinner. Staff and records review also indicated that R1 had sensitive skin and the facility has documented occurrences when they have noticed increase redness on R1’s body. However, the presence of bruising on 8/20/2022 was in direct correlation of R1 being handled in a manner which resulted in bruising. Based on the information obtained during the course of the investigation, there is sufficient evidence to support the claim that staff handled resident inappropriately, resulting in R1 sustaining bruises. This allegation is deemed Substantiated at this time. Regarding the allegation: Facility did not fulfill reporting req uirements It was alleged that the facility failed to report the unusual incident to the Department. Interviews and record review confirmed that the bruising was reported to Director of Wellness and to the Director of Resident Care Services on 8/20/2022. In addition, staff also communicated the incident to R1’s responsible party. However after review of internal records, the facility did not submit an Unusual Incident Report to Community Care Licensing documenting the occurrence of the bruising. Based on the information obtained, there is sufficient evidence to support the claim that the facility did not fulfill reporting requirements. This allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. In summary, the majority of staff noted that they become familiar with care needs by discussing resident care needs amongst one another during the overlap shift times, they review care notes in the online system, they can review assessments, and they can also discuss care needs with the resident themselves. It was communicated that the information is available to staff and that it is an expectation that staff become familiar with residents upon move in. It was also communicated that staff are sometimes unaware of new residents until they are assigned to care for them. However, it was noted that information pertaining to new residents is discussed and documented for all staff to review. It was mentioned that Resident #2 (R2) had extensive care needs that were not communicated or discovered until R2 was admitted to the facility. The LPA audited R2’s file during today’s visit and noted that R2 was admitted on 8/20/2022 yet was assessed on 8/18/2022 and was deemed appropriate. Interviews supported claims that staff have received training on how to safely meet R2’s needs and can employ several resources and methods to obtain additional information about R2, including speaking to the Directors, Nurses, and R2’s family. At this time, staff in general feel that they know how to manage R2’s care. Yet, there were inconsistent statements shared as to whether all staff were aware as to how to properly care for R2 upon admission to the facility, as some staff felt ill-prepared to properly assist R2. Based on the information obtained, there is insufficient evidence to support the claim that staff are not up to date regarding resident care needs. This allegation is deemed Unsubstantiated at this time. However, it appears that R2’s appraisal and/or physician’s report may not accurately reflect R2’s current care needs and capabilities. This will be addressed in a case management report. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.