complaint·September 12, 2024

Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas. Requested and obtained the following documents for Residents# 3: Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA conducted interviews with four (4) staff members and two (2) residents. LPA observed resident rooms to be free of hazards. Investigation Branch, Investigator Olivia Spindola conducted further investigation. Regarding the allegation: (1) Due to staff neglect, residents fell resulting in injury. (2) Staff did not seek timely medical attention for the resident. (3) Staff did not follow the resident’s fall plan. Four (4) out of four (4) staff denied the allegation. Two out of (2) residents could not corroborate the allegation. It is alleged that resident R3 had an unwitnessed fall and sustained injuries in the early hours of the morning, on 09/01/2023. Caregivers discovered R3 on the floor near the bed. Staff put R3 back in bed and did not notify the Facility Administrator, did not make assessment of the fall. According to staff statements (investigated by Spindola), morning caregiver mentioned R3 was feeling very sore and complained of pain. Caregiver(s) did not apply fall care assessment to resident. After breakfast, upon rising from dining seat R3 screamed in pain, was sent to Pomona Valley Hospital for emergency medical care. Investigator Olivia Spindola conducted further investigation. R3 was diagnosed at Pomona Valley Hospital with multiple fractured left ribs and punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The Individual Service Plan dated 02/16/2023, received by Mountain View facility, noted that R3 was totally dependent, need assistive devices; needs walker and wheelchair, shower chair. Section C page 9 of the assessment tool indicates resident is at risk for falls. Section C page 24 identifies risks to personal safety; potential for falls, unsteady gait and fall history. Residential appraisal dated 03/17/2023, indicates under services needed: balance is off, very wobbly. Bathing: needs to be monitored so they do not fall. Functional Capability Assessment dated 03/17/2023 indicates balance is off. 06/03/2023, R3 had a fall in the patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off their bed and hit their head. On the early morning hours of 09/01/2023, caregiver found R3 on the floor near their bed, and put R3 back into bed without assessing them. Overnight shift caregivers did not inform the facility administrator nor seeking medical attention and failed to render R3 services needed, due to fall plan not being followed as shown in the documents reviewed. Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to Resident # 3, (1) Due to staff neglect, residents fell resulting in injury. (2) Staff did not seek timely medical attention for the resident. (3) Staff did not follow the resident’s fall plan. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect. Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, and appeal rights were provided.