complaint·September 13, 2023

Little Company of Mary, 1Heart Hospice/Pallative Plan of Care. A separate investigation was conducted by the Department of Social Services Investigation Bureau by Investigator Jose Santana that included a review of hospital medical records, hospice plan of care, and interviews with hospital medical personnel, local law enforcement, hospice agency staff, witnesses, and facility staff. Regarding Allegation #1 : this investigation revealed that based on a review of Resident #1’s chest x-rays (between 10/31/22 and 05/04/22), Resident #1’s bilateral rib fractures occurred at the facility on at least two (2) occasions: once between 11/03/22 and 03/14/22 and once between 03/14/22 and 05/02/22. Witness #5 explained that these fractures did not look acute at the time of imaging; but beyond this, it is not possible to say how old they are, and that Resident #1 was more susceptible to a fracture because of the resident’s osteopenia (bone loss) and there were a multitude of possible causes for these fractures - outside of physical abuse; including coughing and falling. Per Witness #5, Resident #1’s fractures are not concerning for abuse because rib fractures are common among the elderly and bilateral rib fractures typically mean separate points of impact; such as, from falling more than once. Witness #10 did not feel that Resident #1 required a higher level of care than routine. [A review of R1’s physicians report (dated 10/23/21) does not document that the resident is a high risk for falls; however, a review of R1’s Resident Appraisal (dated 04/29/22) documented R1 is a fall risk. A review of R1’s Enhanced Residential Care Services Need Tier Assessment (dated 10/27/21) documented an annual fall-risk assessment.] Interviews conducted of seven (7) facility staff members, the majority corroborated that they have not observed a facility staff member physically abuse the resident or a resident in care. Interviews conducted of four (4) residents, the majority corroborated that they have not been nor have they observed residents in care being physically abused by a facility staff member. Interviews conducted of fourteen (14) witnesses, the majority corroborated that they did not suspect facility staff were physically abusing Resident #1 and that the resident was not in imminent danger at the facility; as the facility was providing the basic care necessary. Witness #4 stated that a visit from the L.A. County DHS Nursing Team conducted on 05/20/22 found no signs of abuse nor complaints from the residents in care. [A review of facility staff training records documented completed training courses on the topics: “ Needs & Services Training for Resident #1 ” was provided on 04/28/22, “ Mandatory Reporting ” was provided during their hiring process, and “ Personal Rights ” was provided on 10/11/22]. Based on the evidence gathered, interviews conducted, and records reviewed, 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 of PHYSICAL ABUSE: Resident sustained fractures while in care is found to be UNSUBSTANTIATED. Regarding Allegation #2 : this investigation revealed that the contusions to Resident #1’s wrists and arms that were discovered on 04/25/22, the bruise pattern appeared consistent with finger and palm imprints. Staff #2 (S2: Jake Amoyot, House Manager) stated they may have been caused when Staff #2 placed their hands on Resident #1 as a contact (guard assist) due to Resident #1’s agitation and attempts to exit the facility on 04/22/22. Resident #1 was being redirected by Staff #2 and this was done to protect the resident from falling or otherwise injuring themself. Interviews conducted of seven (7) facility staff members, the majority corroborated that they have not observed a facility staff member physically abuse a resident in care. Interviews conducted of four (4) residents, the majority corroborated that they have not been nor observed a resident in care being physically abused by a facility staff member. Interviews conducted of Fourteen (14) witnesses, the majority corroborated that they did not suspect facility staff were physically abusing Resident #1 or other residents in care. Witness #12 stated that Resident #1 was recently prescribed a new medication that could cause bruising. [A review of R1’s medication administration record (April 2022) was observed for documentation and the prescribed medication was being administered, effective 04/24/22. A review of the facility's staff training records documented completed training courses on the topics: “ Needs & Services Training for Resident #1 ” was provided on 04/28/22, “ Mandatory Reporting ” was provided during their hiring process, and “ Personal Rights ” was provided on 10/11/22. Based on the evidence gathered, interviews conducted, and records reviewed, 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 of PHYSICAL ABUSE: Staff physically abused resident while in care is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Staff #1 (S1: Christian Galas, Caregiver A.M.)