complaint·May 19, 2023

Investigations revealed: Regarding allegation: Resident sustained injury due to staff handling resident in a rough manner. It was alleged that resident sustained a skin tear on right arm about 2-3 inches long on 4/29/2023. Based on the Department’s records review, R1 was admitted to the facility on 2/8/2023. R1 is diagnosed with a dementia. The department interviewed six (S1-S6) staff, three residents (R1-R3), and two witnesses (W1-W2). Six staff (S1-S6), two residents (R2-R3) denied that R1 sustained injury due to staff handling resident in a rough manner. R1 claimed S6 grabbed R1’s arm roughly and verbally threatened R1. S5 stated R1 was noticed with a skin tear after a routine diaper change. S5 stated two staff (S5 and S6) assisted R1 with diaper change to provide extra care for R1’s fragile skin. S5 stated the cause of R1’s skin tear is unknown and unnoticed. During interview with S6, the department observed S6 was stuttering and had difficulty speaking. S5 informed the department that S6 has a difficulty in speech but S6 is able to perform the assigned tasks. W1 and W2 revealed R1 has sensitive and fragile skin and R1 had prior skin tear on right forearm in a different facility. W2 stated R1 sustains bruises due to medications and skin condition. Based on gathered information, there is no sufficient evidence that r esident sustained injury due to staff handling resident in a rough manner. Based on information gathered, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegation is Unsubstantiated. An exit interview was conducted with Area Manager Irene Formentera and a copy of the report was provided. Investigations revealed: Regarding allegation: Staff did not notify resident's authorized representative of incident. It was alleged that the facility staff did not call and tell R1’s authorized representative the R1 had been injured on 4/29/2023. Based on the Department’s records review, R1 is diagnosed with a dementia and R1 has an authorized representative. The department interviewed six (S1-S6) staff, three residents (R1-R3), and two witnesses (W1-W2). Based on the department's record review, the facility reported an incident on R1's unusual incident that occurred on 4/29/2023. The “Unusual Incident/injury Report (LIC 624) shows the agencies/individuals notified were the Licensing, Long Term Care Ombudsman, Law Enforcement and the Adult/Child Protective Services, however, the Resident’s authorized representative was not provided a copy of this incident report. Based on interview, W2 revealed R1’s representative was not given a written notice of R1’s injury on 4/29/2023. Interview with S2 revealed R1’s authorized representative initiated a call to the facility and notified S2 that R1 had been injured on 4/29/2023. Based on gathered information, there is sufficient evidence to corroborate the above allegation. Regarding allegation: Staff did not properly care for resident's wound. It was alleged that staff applied a white cream on R1’s skin tear without a prescription or instructions from a medical professional. The department interviewed six (S1-S6) staff, three residents (R1-R3), and two witnesses (W1-W2). Based on interviews conducted, three staff (S3, S4, and S5) and two witnesses (W1-W2) stated R1 was given a treatment by facility staff (caregiver) when R1 sustained a skin tear on the forearm on 4/29/2023. The topical medications applied by the caregiver to R1’s injured arm is called Calmoseptine and A&D. Based on records review, R1 has no prescription of Calmoseptine and A&D from a physician. Based on gathered information, there is sufficient evidence to corroborate the above allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegations, "Staff did not notify resident's authorized representative of incident ” and "Staff did not properly care for resident's wound. " are found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 1,6), the following deficiencies had been observed and citations issued (ref. LIC 9099D). An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Area Manager, Irene Formentera.