Complaint·January 16, 2024

Allegation: Staff are not adequately supervising resident resulting in resident sustaining multiple fractures. It is alleged that resident (R1) has had repeated falls at the facility resulting in multiple fractures. Per record review, on June 8, 2022, resident (R1) fell on their face when getting out of bed. The facility called R1's physician and 911. The resident was transported to Good Samaritan Hospital, and was admitted with a nasal fracture. On 9/4/2022, R1 fell as they were trying to get up. The resident was examined that evening by Primary Care Physician, who determined that the resident did not need to go to the hospital. Staff were instructed to monitor the resident. Home health services were already being provided R1 to address General Muscle Weakness. The resident is ambulatory, uses a wheelchair to ambulate around the facility, and does not require one-to-one assist. On 9/8/2022, the resident reported to staff that they were having pain on the side of the body they fell on. Facility staff notified R1's Primary Care Physician, and per MD note it states that staff were informed that the physician would exam the resident that evening, but staff called 911. According to staff interviews, facility protocol is to to immediately send out residents to the hospital for an evaluation when they sustain a fall, or get injured. On 9/8/2022, R1 was admitted to LAC/USC Medical Center with a left hip fracture. Based on interviews conducted, all staff, residents, and 3rd party providers interviewed denied the allegation. Resident (R1's) physician's office stated that the facility has great communication, and appear to be attentive to residents' needs. Based on the above information and documentation provided there is insufficient evidence to corroborate negligence or lack of care on behalf of facility staff. Based on interviews conducted and record(s) review, there was insufficient evidence to prove the allegation. 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 Roxana Aparicio. A copy of the report will be emailed due to printing issues.