complaint·January 29, 2024

(Cont from 9099) Staff interviews conducted on 07/24/2023 at 11 am, revealed that upon admission to the facility, Resident #1 (R1) required help with all ADLs (Activity of Daily Living). R1 is wheelchair bound and staff uses a Hoyer Lift to transfer R1 to and from their wheelchair and bed. R1 only able to feed themself and used a wheelchair to get around the facility. Interviews with staff and interested parties conducted within the same day on 07/14/2023, revealed that staff had noticed R1s legs were bruised, swollen and painful to the touch. Facility progress notes revealed that R1 sustained fractures t o their right tibia and fibula sometime between 06/16/2023 and 06/17/2023 and on 06/17/23 at 5:42 pm R1’s legs observed to be bruised, decolored and swollen. However, staff had no knowledge of how R1 sustained injuries. No one reported a fall incident involving R1. Information received revealed that although staff noticed swollen areas and discoloration on R1’s legs, staff failed to notify the family about R1’s condition and further investigate the cause of injuries. On 06/18/2023, during evening hours, via zoom meeting, staff told interested parties that R1 was not getting better and “R1 also had tiny bruises on their arms.” A few hours later R1 was hospitalized after interested party came to the facility and called 911. On 06/23/23, R1 was return to the facility and no X-rays were done at the hospital. On 06/27/23 X-rays were ordered by R1’s doctor, and it was determined that R1’s swollen legs and discoloration were due to R1’s fracture of left fibula and tibia. Based on medical record review, R1 suffered from fracture and bruises, which could be a consequence from the fall and/or improper transfer assistance. Based on interviews, observation and medical record review, there is a sufficient information to conclude that resident sustained unexplained injuries due to neglect and/or improper care and supervision. Therefore, the allegation is SUBSTANTIATED at this time. Deficiencies issued per CA Code of Regulations, Title 22. See LIC9099D. Exit Interview conducted. Copy of report given.