complaint·June 13, 2025

Regarding allegations “Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture and Staff did not seek medical attention to resident”: It was reported that Resident #1 (R1) is a fall risk and facility does not provide adequate supervision. On 10/21/2024, R1 was transported to dialysis appointment, and it was observed that R1 was not able to transfer from wheelchair to the chair for dialysis chair for treatment. It was revealed that R1 had a fall at the facility on 10/20/2024 and facility did not seek medical attention for R1. The clinic called an ambulance and R1 was taken to Hospital. It was determined that R1 sustained a fracture. During the course of the investigation, records were reviewed, and interviews were conducted with residents and staff. The review of the facility records revealed R1 was independent and able to leave facility unassisted. The interview with staff revealed 911 was called on 10/20/2024 for R1 due to unwitnessed fall outside the facility. Staff further stated R1 refused medical attention when the paramedics arrived and was subsequently monitored by staff for signs of a change in condition. The review of the LA City Fire Department records confirmed that on 10/20/2024 at approximately 12:17pm, facility staff called 911 for R1 post fall incident outside the facility and R1 refused medical attention. Staff reported that R1 was monitored and complained of pain during the night but refused medical attention. On the morning of 10/21/2024, R1 went to scheduled dialysis appointment. At the appointment R1 was unable to transfer self onto treatment chair at the clinic and disclosed fall incident. Staff from the dialysis clinic called 911. R1 was transferred to the hospital due to complaint of right hip/leg pain from the mechanical fall R1 sustained the day prior. R1 was diagnosed with a closed fracture of the right pubic ramus. The interview of facility staff and records reviewed revealed that, on 10/20/2024, 911 was called immediately after becoming aware R1 sustained an unwitnessed fall. In addition, R1 was monitored by facility staff after refusing medical attention from paramedics, and staff did not observe a change in condition the following morning as R1 was still able to transfer (unassisted) onto wheelchair. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture and Staff did not seek medical attention to resident” is deemed UNSUBSTANTIATED at this time. Regarding Allegation “Staff does not ensure resident's medical needs are being met”: It was reported that R1 requires maximum assistance in transferring and assistant device to transfer resident from wheelchair to clinic chair for treatment session for dialysis. Interview conducted with staff and records reviewed revealed that R1 had a mechanical fall and therefore had difficulty in transferring. R1 was hospitalized and returned from the hospital on 01/01/2025 with no changes. R1’s service plan was updated on 01/06/2025. R1’s diagnosis included congestive heart failure, gastroesophageal reflux disease; coronary artery disease, renal failure and hypothyroidism. R1 is non-ambulatory wheelchair dependent who was able to perform all ADLs independently except for showers. R1 wore a prosthesis on right leg and had bladder impairment. R1 was noted as being able to respond to verbal commands, follow instructions, manage own incontinent care needs, able to make decisions and leave facility unassisted. According to staff R1’s medical needs are met. R1 expressed being satisfied with the facility. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff does not ensure resident's medical needs are being met” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Staff does not ensure resident is being transferred to medical appointments in a timely manner”: It was reported that R1’s dialysis schedule is Monday, Wednesday and Friday from 7:30am-10:45am. It is alleged that R1 has been late multiple times to the appointments and therefore R1 receives partial treatment. Staff interviews and records reviewed revealed that R1 was late to a couple appointments due to the transportation company running late. Facility staff made changes and arrangement was made with a different transportation company. R1 confirmed the change and expressed that they are satisfied with accommodations made by facility staff in regard to the scheduling and meeting transportation needs. Random residents interviewed did not report any issues or concerns with transportation arrangements made by facility. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff does not ensure resident is being transferred to medical appointments in a timely manner” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Staff left resident soiled”: It was reported that R1 was left in soiled clothing and sent out to scheduled medical appointment. Staff interviews and records reviewed revealed that R1 is able to meet own toileting needs and if need staff assist. If R1 requires any assistance with ADLs R1 would alert staff for assistance. Staff reported the for the most part R1 is still able to toilet self. R1 confirmed being independent and able to handle own ADLs. According to staff R1 leaves the facility for scheduled medical appointments in dry clean clothing. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff left resident soiled” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report issued.