Inspector’s narrative
What the inspector wrote
Continued from 9099
At approximately 3:15pm, the LPA and staff toured the facility indoors/outdoors; LPA conducted a file review and obtained copies of pertinent documentation at approximately 3:30pm.
Investigator Garcia attempted to conduct interviews with the administrator on 05/06/2022 and 06/06/2022. On 06/10/2022, at approximately 4:30pm, conducted interview with the administrator; on 05/06/2022 attempted to conduct an interview with the assistant administrator; on 07/07/2022, at approximately 6:00pm, conducted interview with assistant administrator; on 07/06/2022, at approximately 1:00pm, and on 07/29/2022 at approximately 4:00pm, attempted interview with Staff #2 (S2); on 08/09/2022, from approximately 10:30am to 12:30pm, conducted interviews with assistant administrator, Staff #1 (S1), R1, and Resident #2 (R2); on 09/08/2022, from approximately 10:00am to 3:40pm, conducted interviews with S2, and R1’s resident representatives; and on 09/14/2022, at approximately 12:00pm, conducted an interview with Witness #1 (W1). Additionally, Investigator Garcia reviewed copies of medical records and photographs of R1’s injuries.
The investigation revealed that on 05/01/2022, R1 sustained an unwitnessed fall. According to the Unusual Incident Report, on 05/01/2022, the staff placed R1 on the commode at approximately 3:30pm and then found R1 on the floor approximately 3:30pm. Per the staff, R1 denied pain and did not receive immediate medical care. Per the assistant administrator, the next day, she assessed R1 sitting in a wheelchair with slight pain noted on the left leg. R1’s resident representative was notified to have R1 evaluated at urgent care. The assistant administrator stated they called the taxi service and requested transportation for R1. At approximately 5:00pm she received a phone call from the taxi service advising her they were no longer providing transport services for the residents. Investigator Garcia contacted the taxi company and it reflected that there was no records the facility had called or placed an order. At 5:00pm the caregivers informed her that R1 was ok and did not need to go to the hospital. She advised the staff to observe R1 for the night. On 05/03/2022, at 7:30am, S2 called the assistant administrator to report swelling with bruising on R1’s left leg and texted a photo. At 8:30am, staff were informed to not move R1, give Tylenol and call 911. R1’s resident representative was notified and R1 was sent to the hospital.
The Kaiser Permanente medical records reviewed indicate on 05/03/2022, at 10:00am, R1 was presented to the hospital for evaluation following a fall. R1 reported a ground level fall in the bathroom (1) week ago.
Continued from 9099-C
R1 noted lower extremity pain, swelling and bruising to the left ankle and lower leg prompting presentation to the Emergency Department for further evaluation. R1 stated they are usually wheelchair bound and does not ambulate. It was notated that R1 has a history of falls and unsteady gait. X-rays were taken and demonstrated fracture of the distal tibia, fibula and proximal fibula. Physician discussed with R1 that typically this fracture pattern indicates surgery for maintenance of alignment and ankle stability. However, since R1 was non-ambulatory with medical comorbidities that make risks of surgery outweigh the benefits. R1 agreed and was placed in a cast and discharged back to the facility.
The hospital records also noted neglect issues. It was revealed that while R1 was assessed at the hospital, the social worker (LCSW) contacted the assistant administrator to inquire if R1 had fallen a week ago. The assistant administrator reported that R1 fell the day before yesterday (05/01/2022) and did not believe R1 had a fall a week ago, but that R1 was seen crawling on the bathroom floor a week ago. Assistant administrator stated they assessed R1 and R1 did not report having any pain. The LCSW received a referral from the bedside RN due to concerns about R1’s fall. Per the RN, R1’s bruising appeared to be in different stages of healing. Per chart review R1 fell while transferring to a wheelchair over a week ago.
During the interview with investigator Garcia, R1 stated that on one occasion they fell off the bed and that they kept screaming for help because they don’t have any type of emergency alarms in the bedrooms. R1 stated that two staff came into the room and assisted R1 back to the bed. But R1 reiterated they kept telling the staff that they wanted to go to the hospital because they were in so much pain. R1 stated they kept complaining to the staff, but they did not listen. R1 stated they ended up taking R1 several days after, and when the hospital took x-rays they saw several fractures.
Information obtained through interviews found that staff were unable to provide consistent statements regarding the appropriate level of care provided to R1. Additionally, they were unable to provide any notes regarding R1’s care, R1’s leg/foot condition, Doctor’s recommendations, or supervision logs. The staff stated that when R1 was found on the floor, R1 did not complain of any pain, therefore, no medical attention was immediately sought. The staff were aware that R1 was a fall risk and confirmed that in several occasions, R1 “would slide off” bed and was found crawling on the floor. Vague statements were provided regarding the level of care and appropriate safety measures in order to prevent further injuries.
Continued from 9099-C
Based on the statements provided, documentation and photographs obtained, the Department has sufficient evidence to support the allegations. Therefore, the above allegations, “ Resident sustained an unwitnessed fall resulting in injuries” and “Facility failed to seek medical attention in a timely manner” are deemed SUBSTANTIATED at this time.
A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
