other·August 23, 2021

On 08/14/2019, 11/02/2019 and 11/06/2019, Investigator Douglas conducted interviews with facility staff and residents. On 08/14/2019, 08/20/2019, 8/22/2019, 09/19/2019 and 10/25/2019, Investigator Douglas conducted interviews with Detectives from Los Angeles County Sheriffs Homicide Division. On 11/06/2019, interviews were conducted with Home Care Assistance personnel, which was the private agency who provided one-on-one (1:1) supervision for R2. Investigator Douglas obtained and reviewed Hospital Medical Records on 07/25/2019. Moreover, facility video surveillance footage and other pertinent documentation was also reviewed by Investigator Douglas. Record reviews and interviews conducted regarding the incident revealed that, on 07/13/2019, R2 pushed R1 in the back causing R1 to fall face first on the ground and R1 was observed bleeding from R1’s nose, mouth and forehead. The attack was unprovoked and without warning. Several staff members were present in the area of the facility where the incident occurred and witnessed the attack as it occurred. As a result of the injuries, R1 was transported to the Emergency Room (E.R). Per medical record review, R1 was admitted to the E.R. on 07/13/2019 and was diagnosed with the following: stable burst fracture of the first cervical vertebra, acute respiratory failure - unspecified with hypoxia or hypercapnia, anterior displaced type II dens fracture, contusion of abdominal wall, contusion of right front wall of thorax, fracture of nasal bones, laceration without foreign body of nose. R1 was terminally extubated per family request and ultimately passed away at the hospital on 07/22/2019. Documents reviewed and interviews conducted revealed that R2 was admitted to the facility on 11/08/2018. Per R2’s physician report dated 08/17/2018, R2 has a primary diagnosis of Alzheimer’s dementia and anxiety. The report further notates, R2 is confused/disoriented, has inappropriate and wandering behavior. The report did not indicate R2 had aggressive behaviors. However, records reflected that R2’s aggressive behaviors dated as far back as 11/16/2018. R2’s Comprehensive Assessment and Service Plan dated 04/23/2019, indicates R2 has some behavioral concerns such as “yelling” and “attempting to strike CG (caregivers).” The assessment further noted that R2 “bit” a caregiver on 04/13/2019. Investigation further revealed that prior to the incident that occurred on 07/13/2019, R2 had a history of numerous aggressive behaviors both verbally and physically towards staff and other residents. On 07/01/2019, R2 hit a caregiver on the arm and once redirected, went into a resident room and hit a resident on the hands. On 07/09/2019, R2 hit a facility staff member. On 07/12/2019, another resident grabbed R2’s arm, and R2 hit the resident on the shoulder in response. As a result of the incident that occurred on 07/13/2019, R2 was placed on one-on-one care from 07/13/2019 (post-incident) through 07/26/2019. Based on all information gathered and reviewed during the course of the investigation, the department has sufficient evidence to determine that due to lack of care and supervision, R1 was pushed by R2, which resulted in R1 sustaining serious injuries. The facility staff were aware of R2’s behaviors; however, they failed to implement adequate safety measures to address and manage R2’s repeated aggressive behavior. It was foreseeable and regularly documented that R2’s aggression posed a risk to other residents in care. Therefore, the above allegation “Due to facility lack of care and supervision, Resident #1 (R1) sustained injury(ies)” is SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report has been issued.