complaint·October 12, 2023

Allegation: Staff failed to provide appropriate care and supervision to resident after the fall. It is alleged that on 5/5/2022, resident (R1) sustained 2 falls. The 1 st fall occurred at approximately 7:30 PM while being provided incontinence care by caregiver (S1) in the facility common bathroom. The 2 nd fall was unwitnessed and occurred in the resident's room at approximately 8:00 PM - 8:30 PM. While staff (S1) was changing R1’s diaper in the common bathroom the resident fell to the ground. The resident was unable to get up on their own or with S1’s help due to their size. Caregiver/Staff (S1) used the Hoyer Lift to pick the resident up from the floor, and then proceeded to walk the resident back to their room. Facility staff failed to use proper equipment and follow equipment use guidelines when assisting R1 with incontinence care that resulted in the first fall in the bathroom. Staff placed R1 in the bed and returned to check on the resident at approximately 8:00 PM – 8:30 PM. Staff (S1) found the resident face down on the ground beside the bed. Staff (S1) stated that they decided to place a pillow under the head, so the resident did not get hurt, since R1 was likely to fall again. Staff (S1) stated the resident only replied “okay". Based on interviews with staff on duty, staff 9S1) and CNA/staff (S2) did not provide appropriate care and supervision after both falls. Review of evidence indicates that staff (S1) placed resident in a harmful situation by placing a pillow under the head (partially covering the face) and left the resident on the floor. Emergency personnel observed the resident's bed did not have any bed rails. Proper safety measures were not in place. Allegation: Staff did not provide medical assistance to resident in a timely manner. It is alleged that facility caregiver (S1) and Certified Nurse Assistant (CNA)/Staff (S2) failed to provide timely medical attention by not rendering or initiating CPR when resident (R1) was not responsive. The facility failed to seek timely medical attention when R1 fell the 2 nd time and was found on the floor. Emergency Medical Services (EMS) were not called almost two (2) hours after resident (R1's) 2 nd fall, instead staff (S1) placed a pillow under the resident's head. Based on the photo, the resident was left on the floor in compromised position that appears to show R1 in prone position with left arm underneath body and right arm extended out in downward position. Caregiver staff (S1) reported both falls to CNA on duty. The 1 st fall occurred at approximately 7:30 PM. The 2 nd fall occurred at approximately 8:00 PM – 8:30 PM. At approximately, 9:30 PM, caregiver returned to the room to check on the resident because 2 other residents were heard screaming from R1's room. The resident was still laying on the ground with head on the pillow. Staff (S1) allegedly placed their index finger under the resident’s nose to see if any air was coming out from the nose. Staff (S1) stated the they felt air and left without providing further aid. According to staff interviews, staff (S1) reported the falls to Certified Nurse Assistant (CNA)/staff (S2). Sometime between 9:00 PM - 9:30 both staff went to check the resident. CNA stated that they stood by the door while staff (S1) checked on the resident and stated that staff (S1) reported the resident was okay. At 10:11 PM staff called EMS and reported to dispatcher that the resident was conscious. At 10:14 PM, EMS personnel arrived at the facility and found the resident "Dead on Arrival". Time of death was 10:17 PM. Paramedics determined the resident had been deceased longer six minutes. ***Narrative continues next page.**** Allegation: Insufficient staff to meet the needs of the resident(s). It is alleged that the facility did not have staff of adequate number and skill to provide care to the residents. When Emergency Medical Services (EMS) arrived staff delayed in allowing emergency responders crew into the facility. In addition, it is alleged that staff did not provide 911 emergency response dispatchers accurate information pertaining to resident's condition. Staff interviews revealed that during the afternoon shift staff (S1) is usually assigned to the front desk and when residents require immediate assistance it become very difficult to assist the residents. The findings indicate that on Saturdays and Sundays staff (S1) is the only person working from 2:00 PM - 10:00 PM; which includes providing the residents with meals, passing out medications, offering them snacks, and changing diapers for all the residents in need. In addition, the graveyard shift (10:00 PM - 6:00 AM sometimes has only one (1) staff working, and two hourly checks are not always performed. Staff interviewed acknowledged that due to staffing shortages, neglect and lack of supervision are likely. On May 5, 2022, both staff on duty (S1) and (S2) failed to provide medical assistance (CPR) or conduct a body assessment on resident (R1). On the resident (R1's) Appraisal/Needs and Services Plan dated 12/3/2020, it states the resident is at risk for falling, needs assistance with daily activities, and daily monitoring/observation will be performed. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited according to Title 22 and Health and Safety Code. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM. The issuance of a civil penalty is being considered based on Health & Safety Code HSC §1569.49(e) – (f) , if the department determines the serious bodily injury was due to neglect. Exit interview was conducted with Peter Babaian. A copy of the report and appeal rights were provided. Allegation: Questionable Death. It is alleged that resident (R1) died at the facility due to neglect of care. On 5/5/2022, at approximately 8:00 PM - 8:30 PM caregiver staff (S1) found the resident laying in a prone position with face down but did not pick-up the resident, only placed a pillow under its head, and left the resident on the floor. Night shift staff placed a 911 emergency call until 10:11 pm. The decedent was found dead by emergency responders. Resident (R1) had bruising on their lower back that led further under the diaper, had a fresh cut on back, and had a visible dislocated left shoulder. A picture was taken, and appears to show R1 in prone position with his left arm underneath and right arm extended out in downward position. Left knee bent with left foot darker color extending pass their ankle. Based on County of Los Angeles Department of Medical Examiner- Coroner Autopsy Report (5/8/2022) and Registrar- Certificate of Death records the cause of death is listed as "Natural". Other conditions contributing but not related to immediate cause of death listed Diabetes Mellitus and lymphoma. There is insufficient evidence to substantiate death as autopsy report ascribe cause of death to Arteriosclerotic Cardiovascular Disease and manner of death as natural. 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 is Unsubstantiated . Exit interview was conducted with Peter Babaian. A copy of the report was issued.