complaint·February 2, 2023

The investigation revealed the following: Allegation - Neglect/lack of supervision resulting in resident sustaining a fracture while in care . IB Investigator T. Brunelli conducted interviews and reviewed records pertaining to Resident #1 (R-1) who fell and fractured a hip on 1/2/2021. According to the Impactactive waiver form that was signed by R-1's family member on 10/31/2019, it authorized the facility to order 3 pairs of hip protection garments for R-1 to use. On 1/2/21, R-1 was not wearing a hip protector, had a fall in the facility courtyard and sustained a hip fracture. Per the interviews with staff, some acknowledged that R-1 had worn a hip protector prior to the fall. During that time period, the facility had many staff off due to testing positive for the Coronavirus. The facility had brought in care staff from outside agency to assist residents and one was assigned to R-1. The caregiver daily assignment sheet dated 1/2/2021 did not indicate that R-1 should be wearing a hip protection garment, as shown with the label "hp" next to some other resident's names. It was verified that R-1 was not wearing a hip protection garment on the day of the fall. Based on the information gathered, there is sufficient evidence to show that there was negligence from the facility for failure to ensure R-1 wears a hip protector, which could had prevented resident from sustaining a fracture. Allegation - Staff did not ensure resident was wearing hip protector. According to current Administrator Carpio, any resident who signs the impactactive waiver form, the facility orders 3 pairs of hip protectors and the staff ensure the residents wear them. The staff are given their daily assignment, and the list will indicate “hp” next to the names of residents who signed up for the hip protection garment. Upon admission, R-1’s family signed up to purchase hip protectors for R-1 to wear, which could help reduce the risk of having a hip fracture from a fall. Based on the caregiver daily assignment sheet dated 1/2/2021, residents who are supposed to wear a hip protector had a “hp” labeled next to the name and was confirmed there is no “hp” indicated next to R-1’s name. Therefore, the registry staff assigned to care for R-1 possibly could not have known that R-1 needed to wear the hip protector. On that same day, R-1 was not wearing a hip protector and sustained a hip fracture from a fall. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** The issuance of an additional Civil Penalty is being considered based on health & Safety Code 1569.49(f); If the Department determines serious bodily injury occurred. An exit interview was conducted. The Plan of Corrections were reviewed and developed with A. Ghammangne. A copy of this report and appeal rights were provided. The investigation revealed the following: Allegation - Resident sustained pressure injuries while in care. It was alleged that Resident #1 (R-1) had open pressure wounds on the ankles and a small pressure wound on the back. Based on interviews conducted with the staff, they recalled R-1's leg being elevated and was wearing a boot. They also stated that the home health nurse was treating the wound. Staff indicated that when they observe redness on any resident's body, they would report it right away to the nurse. Based on the record review, R-1 did have a pressure wound on the ankle in which a home health nurse was treating. It was also noted that R-1 had a firm mass in the lower right back which was discovered on 2/26/21. The medical doctor was notified on the same day and was monitoring the mass. Although R-1 sustained these pressure injuries, there were no sufficient evidence showing a lack of supervision or neglect from the staff. Allegation - Staff did not respond to resident's alarm. It is alleged that Resident #1 (R-1) had several falls due to staff not hearing the tab alarm. LPA Chan interviewed the Administrator and 5 Staff. Administrator stated that staff are constantly walking around to monitor residents, about every 2 hours or more often if needed. Staff denied not responding to resident's alarm. They stated when they hear the tab alarms go off, they will immediately check on residents. The tab alarm, which are clipped on their clothing, are loud enough where staff are able to hear from the hallways. According to staff, R-1 had used a tab alarm but also knows how to remove it to avoid the alarm sound. When staff noticed it was removed, they would reattach it on resident and explain to resident the importance of having it on. Staff also denied R-1 having several falls due to staff not hearing the tab alarm. Staff mentioned that when they arrived in resident's room, R-1 was seen on the ground. However, there were no injuries noted nor was there any witnesses that resident fell to the ground. 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 allegations are UNSUBSTANTIATED. An exit interview was conducted with A. Ghammangne. A copy of this report along with the appeal rights were provided.