Complaint·December 22, 2023

(Report Continued from LIC 809...) During the interview with the Administrator Joeyvic Alvarado, she stated Resident #1 (R1) had a fall on 08/15/2022 and went to the hospital. When the resident was discharged the family opted to move them to a board and care and where R1 subsequently passed away. The Administrator showed the LPA surveillance footage of R1 when they fell. The LPA observed the resident to be walking in the hallway when they pulled on their sweater causing them to lose their balance and fall. Video footage went on to show that staff was nearby the resident when they fell and provided aid to the R1 right away. The Administrator was not aware of R1 having any other recent falls. Interview with a staff present near R1 when they fell stated R1’s fall had nothing to do with staffing. They said R1 was agitated that day and they just happened to fall. Additional interviews with all four staff revealed that there are times when there are only two caregivers during the day shift which makes it difficult to care for the residents, especially when assisting residents who are a two person assist. Interviews also revealed there are some days three caregivers is not enough either to assist residents because that only leaves one person on the floor. The Administrator stated there are always three caregivers scheduled on shift during the day but there are times when a staff will call out sick and there will be only two caregivers on shift. The Administrator stated it may take an hour or two for agency staff to arrive although a manager will stay and assist, or the medication technician will assist until more staff are available. Based on the information obtained, although there is not sufficient evidence to support insufficient staffing resulted in resident falls, staff interviews revealed there are times when they only have two caregivers on shift which is insufficient to meet the residents needs. Therefore, the allegation of Insufficient staffing at the time the complaint was filed is deemed substantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.