complaint·November 29, 2021

Regarding the allegation: Residents sustained a fracture while in care It was alleged that R1 and R2 suffered numerous falls, some resulting in significant injuries, including a fracture. A review of documents for R1 revealed that R1’s initial Comprehensive Assessment and Service Plans dated 10/4/16, 6/29/17, and 8/2/18 did not indicate any falls and R1 was not deemed a fall risk at that time. The Service Plan dated 4/9/19 noted that R1 suffered falls on 12/25/18 and 3/27/19, yet further assessment did not deem R1 a fall risk, nor did it note that R1 needed further assistance. Service Plans dated 10/14/2019 revealed that R1 suffered falls on 9/18/19 and 10/08/19. Whereas no injuries were sustained as a result of these falls, further supports were noted as being put in place, including fall mats, and ‘hip protectors’ to be worn at all times. At that time, it was deemed that R1 was a fall risk. Interviews and documentation revealed that R1 often did not wear the hip protectors as documented in the service plan. R1 ultimately suffered another fall on 10/17/2020, which resulted in a hip fracture. It was discovered that R1 was not wearing hip protectors at the time of the fall, which may have protected R1 from sustaining a hip fracture. Comparatively, R2 also suffered numerous falls in the facility. Per various reports presented in R2’s file, it was indicated that R2 sustained a fall or was found on the floor on the following dates: 4/29/2018, 5/2/2018, 5/7/2018, 12/7/2019, 1/25/2020, 3/5/2020 and 6/12/2020. After reviewing R2’s Comprehensive Assessment and Service Plan dated 10/25/2018, whereas the falls were mentioned, no plan was mentioned on how to address the falls, nor was R2 noted as a fall risk. The Comprehensive Assessment and Services Plans dated 4/9/2019 and 10/10/2019 were provided at the request of the Investigator; however, page 4 was missing from those service plans, which is the page in which documented falls and subsequent fall prevention strategies are mentioned. R2 suffered a fall on 6/12/2020, and R2 was hospitalized and diagnosed with a hip fracture. Interviews revealed that further discussion regarding fall prevention and assistance regarding R2 did not transpire with R2’s responsible party. Based on the investigation, there is sufficient evidence to support the claim that due to lack of care and supervision, residents sustained numerous falls, with some resulting in serious injury. R1’s service plan indicated that R1 would wear hip protectors at all times, yet the investigation revealed that R1 wore them inconsistently. In addition, R2 suffered numerous falls, yet the investigation did not cover any documented plan or course of action to address R2’s propensity to fall. Whereas all falls cannot be prevented, the supports allegedly put in place were not adequate. Based on the investigation, this allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D).Exit interview conducted. A copy of this report and appeal rights were issued. Regarding the allegation: Staff restrained resident It was alleged that Resident #2 (R2) was allegedly restrained to the bed by way of staff tying R2’s foot to the bed. Interviews and records review revealed that on 6/12/2020, R2 suffered a fall at the facility, which resulted in R1 suffering a closed fracture of the right hip. Hospital discharge paperwork described R2’s treatment, which included a 5lbs bucks traction , which according to the US National Library of Medicine, is an apparatus for maintaining proper alignment of a fracture, typically used for a hip or leg fracture. Regular use of this reduces pain and maintains length in fractures. Facility Progress Notes documented that R2 was discharged from the hospital on 6/16/2020, with orders for the 5lbs Bucks traction. Subsequent Facility Progress Notes confirmed that the apparatus was observed on R2 as ordered. Interviews with R2’s family member confirmed the use of this leg traction and stated that it could have been mistaken for a restraint. Based on the investigation, there is insufficient evidence to support the claim that staff restrained R2 to the bed by their foot. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Licensee failed to follow physician’s orders for medical equipment needed for resident(s) It was alleged that residents, including R1, were prescribed to wear hip protectors from their primary care physicians, yet staff did not ensure that they were using them. Interviews with two (2) of the medical professionals responsible for R1’s care confirmed that they did not prescribe R1 to wear hip protectors. However, the third medical professional, whose name was on the Service Plan which stated to use hip protectors, did not respond to the investigator’s request for a comment. In addition, there was no documentation to support the claim that the hip protectors were ordered. Whereas documentation does confirm that R1 was supposed to wear hip protectors, this provision appeared to not be at the request or order of R1’s doctors, but more so a safeguard provided by the facility to assist in fall prevention. Based on the investigation, there is insufficient evidence to support the claim that the licensee failed to follow physician’s orders for medical equipment needed for residents. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.