complaint·April 11, 2024

On 11/04/21, around 3:30am during one of the redirections by staff, (R1) turned around quickly and said to staff, “don’t touch me”, and tripped, causing (R1) to fall, and hit (R1’s) head and left side arm. (R1) was treated with 1st aid by staff. Staff stated the incident was reported to the Administrator and (R1’s) hospice agency. Staff started breakfast around 6:30am and (R1) ate breakfast then around 7am (R1) started complaining about pain in (R1’s) shoulder. Staff reported that upon (R1) complaining about the pain, staff reported the concern to the Administrator and hospice. Staff stated that the hospice nurse arrived around 10am on 11/04/21, treated (R1’s) wound and asked that (R1’s) responsible person take (R1) to get checked at the emergency hospital. The Administrator reported, he missed staff’s call during the night, when it came in around 4am on 11/04/21. Upon hearing the message, around 7am the Administrator immediately called (R1’s) responsible party and hospice. Although the notification was not immediately to the spouse upon (R1) falling, the notification was made within a timely manner which was confirmed by hospice staff who provided medical attention to (R1) on the same morning of 11/04/21. Therefore, based on interviews and documents reviewed, the allegation is deemed Unsubstantiated at this time. Allegation # 2: It was alleged on staff did not provide adequate supervision. On 11/17/21 from 930am to 12pm, Licensing Program Analyst (LPA) Jose Gary Tan conducted the initial complaint visit; conducted interviews and a physical plant inspection, as well as requested and reviewed facility documents. On 12/7/21 from 1245pm to 2pm, LPA Tuesday Cabiness conducted a subsequent visit; interviewed staff and reviewed resident records. According to the information obtained, resident #1 (R1) was admitted into the facility on 11/03/21 for respite overnight stays for 24-hour care. According to interviews with staff and resident # 2 (R2), (R1) had difficulty sleeping throughout the night, and kept walking back and forth, in and out of (R1’s) room, and at one time (R1) was going through the roommate’s (R2) personal belongings. (R1) was agitated, and staff and (S2) reported, being up all night with staff re-directing (R1) back to bed. On 11/04/21, around 3:30am during one of the redirections (R1) fell and injured (R1s) head and arm. Staff witnessed the fall and assisted (R1) by applying first aid. Staff reported to LPAs Tan and T. Cabiness, that he stayed in the room with (R1) the entire evening, due to (R1) not being able to sleep throughout the night. Staff also reported to both LPAs, that staff did not get any sleep that evening. Based on interviews, there is insufficient evidence to prove the allegation, therefore it’s deemed Unsubstantiated at this time. Exit interview and copy of report provided.