Complaint·July 21, 2023

Based on IB’s investigation, the investigation revealed the following. For Allegation 1 – Resident sustained multiple fractures while in care. During the investigation, it was disclosed that facility R#1, that R#1 had experienced two separate unwitnessed falls in his room within a span of two weeks. The initial fall occurred on 09/14/21. In that incident, R#1 was discovered on the floor of R#1 room by a caregiver who called for assistance. A facility Med Tech came to the room and assisted R#1. The MedTech assessed R#1 and determined R#1 was okay and did not need EMS (Emergency Medical Services). R#1 advised Staff that R#1 himself was okay. During the investigation, it was disclosed by staff that on Friday 09/24/21, X- rays were ordered and requested for R#1, because they noticed something was wrong with R#1. R#1 stayed in bed and asked for pain pills. R#1 did not specify why R#1 wanted them. The X-rays were performed at the facility on Monday 09/27/21. It was disclosed that R#1 family member, who is also the designated power of attorney, requested they wait for the X-ray results before taking R#1 to the hospital. The facility agreed. However, R#1 sustained a second fall the following day on 09/28/21. In that incident, R#1 was discovered on the floor by the Med Tech. R#1 advised the Med Tech R#1 was fine. The Med Tech assessed R#1 and again determined that R#1 did not need EMS (Emergency Medical Services). R#1 was ultimately taken to the hospital the following day, on 09/29/21, per R#1’s doctor. R#1 was discovered to have multiple fractures and complained of right sided chest pain due to falls 2 weeks prior. Within the 2 falls R#1 denied needing medical help and did not disclose why R#1 was asking for pain medication, staff made their assessment, did not see any visual signs of injury and determined R#1 did not need EMS. R#1 had half beds rails on his bed, to prevent falls from occurring. R#1 attempted to get up from his bed on his own, in both occasion, R#1 did not ask for help. It cannot be determined is R#1 suffered injuries from the 1st or 2 nd fall or he sustained in some other incident prior to the falls. Therefore, based on all the information obtained during the investigation, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated An exit interview was conducted with Bernice Polanco , Administrator, and a hard copy of report was provided. Allegation - Facility did not seek resident timely medical attention. During the investigation, it was disclosed that facility R#1, indeed experienced two separate unwitnessed falls in his room within a span of two weeks. The initial fall occurred on 09/14/21 and the 2nd fall on 09/28/21. On both incidents, Med tech’s assessed R#1 and determined that R#1 did not need EMS (Emergency Medical Services.) The X-rays were performed at the facility on Monday 09/27/21. R#1’s doctor advised staff to take R#1 to the hospital, 2 weeks after the initial fall. R#1 was discovered to have multiple fractures and complained of right sided chest pain due to falls 2 weeks prior. Therefore, based on all the information obtained during the investigation, the allegation is substantiated. Based on IB’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.