complaint·August 5, 2021

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident sustained multiple falls while in care The complainant reports (R1) fell several times in one day but the falls were unwitnessed. Staff #1 (S1) reports that she found R1 sitting on the floor in front of their wheelchair. S1 assessed R1’s range of motion and assisted them to their bed. At 9:30 PM S1 received a call from caregivers on shift and arrived at the room to find that R1 had fallen again and their wheelchair was on top of them. Another range of motion check was completed and R1 was checked for any bumps, bruises or bleeding, none were found and R1 stated they were in no pain. R1’s movement was a bit off, so the decision was made to call an ambulance to take R1 for evaluation to insure no unseen injuries. Interviews with (S1 to S7) show that 4 out of 7 staff state R1 has a history of falling. Per R1’s records, resident is unable to transfer without aid, but there is no fall care plan in place. Based on LPA’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of "Resident sustained multiple falls while in care " is found to be: Substantiated . California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D. An exit interview was conducted with Susie Fuentes. The Rights were discussed and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report to the Administrator. Allegation: Facility staff did not seek medical attention in a timely manner The complainant reported (R1) did not arrive to the hospital in a timely manner after multiple falls. Interview with (S1) disputes this allegation and states that a non-emergency ambulance was called immediately as (R1) stated they were in no pain and no blood or bruises were found, however there was a several hour wait for pick-up. Administrator states she was informed by (S1) that several ambulance services were called, all stated that there were long waits that evening and it would be several hours before a pick-up could happen. In addition, the transport was delayed and the facility had no other method of transporting the resident. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. The Department’s investigation consisted of an inspection of the facility, observation, analysis of records, incident report, and interviews conducted and found no evidence to support the allegation: " Facility staff did not seek medical attention in a timely manner ". Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated .