Complaint·February 13, 2025

On 06/12/24, IB obtained the following documents gathered from LPA, Raymond Comer, during the course of his initial investigation: R1’s Plan of Care, Resident Assessment, Physician Report, Release of Resident Medical Information, Staff Narrative Charting, Admissions Agreement and other relevant documents. On 6/14/24, IB conducted an interview with Hospice personnel Witness#1 (W1) provider of hospice care for R1. W1 submitted an email to IB investigator stating R1 requires maximum assistance with transfers and is a fall risk. W1’s email response contains a statement from R1’s doctor showing that R1 is 100% dependent for all care needs. Communications log submitted by W1 shows, that on 10/31/23, facility staff were aware that R1 was in extreme pain and not physically able to stand, nor move their leg without experiencing a lot of pain, and that Hospice agency was not notified of R1’s fall injury. On 08/15/24, IB conducted an interview with staff 1 (S1), who confirmed that R1 had sustained a fall from their bed on 10/30/ 2 3 around 01:00am. S1 states that on 11/01/23, they inquired to the responsible caregivers about the falling incident. The caregivers responded that they, “…didn’t think it was necessary to report it”. S1 states that disciplinary actions were taken against the responsible caregiver staff for failing to report at the time of the incident’s occurrence. On 8/19/24, IB conducted a subsequent interview with W1 who spoke with IB investigator, via phone, and stated the following: W1 contacted facility staff and Administrator asking if R1 had fallen; Staff and Administrator, “kept saying no”. W1 stated to IB investigator that protocol requires, “…when a patient falls, the expectation of the facility is to contact hospice immediately. We have to be notified immediately…”. On 08/20/24, IB conducted an interview with staff 2 (S2), who assisted R1 at the time of the reported incident. S2 confirms that they did not conduct a physical check of R1 for any injuries, stating, “I messed up on that aspect”. On 8/28/24, IB conducted a records review of relevant documents submitted by Kaiser records department. IB’s review of records reveals, on 11/03/23, R1 was admitted for a left hip fracture due to a fall injury which occurred at the facility. Noted comments indicate R1 sustained a fall on 10/31/23, and was put back to bed with no concerns, and that family was not informed of the injury until the following day. [continued on LIC9099C] On 08/30/24, IB conducted an interview with staff 3 (S3), who stated that, if an injury is suspected, staff are trained to check residents for any bruises, report the incident to their supervisor, and call 911 if there is any pain or bleeding. S3 states that staff did not report the incident, in spite of R1’s constant complaints of pain, saying that R1 always complained of pain, “which was normal behavior for R1”. On 9/04/24, IB conducted an interview with facility staff 4. (S4) who stated they were not at the facility and the time of the incident involving R1. However, S4 stated concerns of the facility not having enough staff to keep the residents safe. On 09/09/24, IB conducted an interview with resident 2 (R2), who was present at the time of the incident involving R1. R2 stated they were awakened from the sound of screams coming from R1’s room. R2 went looking for staff to assist R1 because it appeared R1 was in a great deal of pain. Based on interviews with staff, residents, and review of relevant documents, it appears that facility staff failed to report R1’s suspected falling incident to supervisory staff, nor provide required medical assessment and treatment in a timely manner. Therefore, pursuant to Title 22, Division 6, Chapter 1, the above allegation(s) are Substantiated. An immediate Civil Penalty of $500.00 is being issued today; Refer to LIC 421M. An additional Civil Penalty determination may be assessed at a later date. Exit interview conducted, appeal rights discussed, and a copy of the report was given.