complaint·May 29, 2024

Pg. 2 On 02/08/2024, from approximately 9:43am to 10:53am, Investigator Bendana conducted interviews with residents, R1, licensee/administrator, and staff; on 03/11/2024, at approximately 2:43pm, with S1; on 04/15/2024, at approximately 9:20am, with R1’s resident representative; and on 04/17/2024, at approximately 2:54pm, with the reporting party. In addition, Investigator Bendana reviewed Glendale Adventist Medical Center medical records, Palermo Hospice medical records, and facility file documents related to R1. According to the facility file documents reviewed, R1’s physician’s report, signed and dated by the physician on 07/10/2023, listed R1’s primary diagnosis as heart disease, dementia, and muscle weakness. It is noted R1 has mild cognitive impairment with an unsteady gait. R1 is confused and disoriented at times but can communicate and follow instructions. R1 needs assistance with activities of daily living (ADLs), is non-ambulatory, not able to transfer to and from bed, and uses a walker. Under the comments, it is noted that R1 is a fall risk and needs maximum assistance. R1’s appraisal needs and services plan, dated 08/01/2021, also indicated R1 needed assistance with ADLs, and needed assistance moving around the facility due to poor functioning body and needs full assistance in using functioning skills. The preplacement appraisal information for R1, dated 07/25/2021, listed R1 cannot ambulate independently due to muscle weakness. The investigation revealed that R1 had been a resident at the facility for approximately three years and had been frequently getting UTIs (urinary tract infections). On 01/06/2024, the licensee/administrator called R1’s resident representative to inform that R1 was “confused” and suggested “maybe” R1 needed medical care. R1 complained about pain in the “abdominal area and back” which R1 complained about when R1 had UTIs. R1’s resident representative then came to the facility to find R1 in excruciating pain and transported R1 to the Glendale Adventist Medical Center. Pg. 3 A review of the medical records indicated R1 was admitted to Glendale Adventist Medica Center on 01/06/2024 with the chief complaint of back/abdominal pain, nausea, vomiting and confusion. History of UTIs, hypertension, dyslipidemia presented to the emergency room with altered mental status. Patient (R1) was brought into the emergency department for generalized weakness, more altered than usual, with chills and weakness, abdominal pain. A CT scan without contrast of the abdomen/pelvis was conducted which revealed an acute T11 compression fracture. On 01/10/2024, R1 was discharged with a diagnosis of Covid-19 virus infection; altered mental status, and UTI. A review of the Palermo Hospice medical records indicated R1 was placed on hospice care at the facility on 01/11/2024. The records listed the chief complaint as chronic ischemic heart disease. R1 was also listed as non-ambulatory, bed bound, or wheelchair needed maximum assist, and a high fall risk. The information obtained from interviews revealed that the licensee stated R1 did not have any falls but that maybe R1 suffered the fracture on the way to the hospital, at the hospital, or maybe at the facility. The facility staff denied that R1 had any falls. S1 claimed R1 did not fall. S1 explained when assisting R1, R1 stated they were in pain, R1’s “back” was “hurting” and did not want to “get up.” S1 said they did not know if R1 was given pain medicine; it was “not” S1’s “responsibility” to “give” R1 medicine. S1 claimed R1 did not have a fall under S1’s care and could not explain why R1 was in pain. S1 remembered R1 complained of pain “all day.” S1 stated S1 informed the licensee/administrator who then notified R1’s resident representative. The investigation further revealed that R1 reported to R1’s resident representative, that S1 dropped R1 while assisting R1 in the bathroom. R1 reported that “S1 dropped them, they fell on their butt, and it really, really hurts”. Furthermore, the CT scan at the hospital revealed R1 sustained a T11 compression fracture. Pg. 4 On the allegation “Staff caused an injury to a resident while in care” - the Department’s investigation provided sufficient evidence to substantiate neglect/lack of supervision . Medical records showed R1 sustained a T11 compression fracture. R1 reported S1 “dropped” R1 . R1 stated they complained of pain. R1’s resident representative stated R1 was in “excruciating pain” and would scream when R1 was moved or tried to move. The licensee/administrator stated R1 may have fallen at the facility. S1 failed to adequately assist R1 resulting in R1 sustaining a T11 compression fracture, therefore, the allegation is deemed 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) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued