complaint·March 3, 2023

Report's (SIR's), Physician's Report, medical records from PIH Downey, Southland Care, Kindred Hospital and review of documentation by Program Clinical Consultant Department of Social Services and interviews with residents and physician. In regards to the allegation Resident sustained unexplained fracture while in care, based on interviews conducted and information gathered there was no witnessed fall for R 1 and based on medical records and witness statements the fall was unforeseen. R 1 was under the Assisted Living Waiver Program and Individual Service Plan updated every 6 months. As part of the Waiver Program Home Health conducted monthly visits to assess R 1. Home Health identified and documented service plans including. but not limited to Risks for falls/injury, activity intolerance, impaired skin integrity and Dementia and forgetfulness. Based upon interviews and records reviewed, the findings indicate that 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. In regards to the allegation Facility did not seek timely medical attention for a resident in care, based on interviews conducted and information gathered R 1 received medical care from PIH Downey, Soutthland Care, and physician for R 1. R 1 most likely suffered a hip fracture from an unwitnessed fall and was transported for medical care on 11/06/2021 at 1400 hours. R 1 was transferred via ambulance to PIH Downey as soon as it was identified by staff. R 1 was in a wheelchair and vital signs were checked and assessed for pain. R 1 was under the Assisted Living Waiver Program and Individual Service Plan updated every 6 months. As part of the Waiver program Home Health conducted monthly visits to assess R 1. Home Health identified and documented service plans including. but not limited to Risks for falls/injury, activity intolerance, impaired skin integrity and Dementia and forgetfulness. Based upon interviews and records reviewed, the findings indicate that 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. In regards to the allegation Facility did not notify resident’s representative of unusual incident, based on interviews conducted and information gathered staff interviewed stated that regarding R 1 the protocol if there are falls or any need for a resident to go to the hospital the family is immediately notified and also the physician. Staff stated that this was the only time that R 1's family member was notified that R 1 needed to go to the hospital as there were no witnessed falls previous to 11/06/2021. Staff stated that client notes were documented 11/06/2021 stating that family member, physician and assistant administrator was informed when R1 had hip pain and an ambulance picked her up. LPA observed client notes stating that family was notified 11/06/2021 and also family member had called the facility at 10:30 PM with a status update. Based upon interviews and records reviewed, the findings indicate that 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.