Incident investigation·January 16, 2025

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident. LPA met with Regional Nurse Specialist Laken Lacy and explained the reason for the visit. A self-reported incident related to Resident #1 (R1) was received in the Woodland Hills Regional Office on 12/27/2024. Incident Report indicates "noted with an abrasion to R1's right knee. Injury obtained during transfer." LPA called the facility to inquire the circumstances surrounding the transfer and requested additional documents to be faxed to the Woodland Hills Regional Office, which were received on 12/31/2024. During LPA's visit today, LPA interviewed Regional Nurse Specialist beginning at 10:37AM, toured the facility with Regional Nurse Specialist at 01:19PM and LPA obtained copies of pertinent documents. No immediate health and safety hazards were identified during facility tour. Interview and document review revealed that R1 had previously undergone right knee replacement prior to R1 moving into the facility. Interview with Regional Nurse Specialist revealed that R1 does require transfer assistance and on 12/22/2024, an agency staff was assisting R1 with transferring between wheelchair and bed when R1's right knee bumped the wheelchair. R1 was observed with a small abrasion but did not report nor appear to be in any pain at that time. The following day, R1 appeared to be in pain, so R1 was sent to the hospital for additional medical attention. Hospital records reviewed indicate "apparent fracture of the distal femur above the site of the prosthesis." R1 returned to the facility with a knee immobilizer and pain medication. Follow up was scheduled with orthopedic specialist on 01/16/2025. Records reviewed do not indicate the injury is acute, nor do records indicate the fracture was sustained as a result of improper transfer or that the injury occurred due to lack of care and supervision. Based on the information obtained there is insufficient evidence to determine whether lack of care and/or supervision contributed to the injury R1 sustained. No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.