complaint·April 4, 2022

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident sustained injuries while in care. The details on the complaint states resident #1 (R1) sustained injuries while in care. The complainant claims (R1) lives at this facility and has sustained bruises on his body while in care. The most recent was on 02/20/22 when (R1) had fallen off his wheelchair and sustained injuries. On 03/07/22 witness #2 (W2) came for a visit and confirmed (R1) had sustained injuries with bruises on the face. The Department reviewed (R1’s) service records and attempted an interview during the visit and was unable to hold a conversation as a result of his health condition. The Department observed (R1) with multiple bruises on his face. An interview with administrator staff #1 (S1) claims she was not made aware of the incident on 02/20/22. Otherwise, she would have taken action to have the resident examined at the hospital. Interviews with staff #3-#5 (S3-S5) all verified they did not notice (R1) any injuries on 02/19/22, however, they did observe him with bruises on his face 02/22/22. They did not inquire about (R1's) condition as there were no notes indicated on the daily progress notes for (R1). An interview with staff #2 (S2) who was present on the day of the incident claims (R1) was found on the floor in front of the television room and had signs of redness on his upper forehead. (S2) applied an ice pack and no other injuries were visible at the time. (S2) claims the incident happened at approximately 2:30 pm on 02/20/22 during a shift change. (S2) reported this incident to the responsible party and nurse practitioner witness #3 (W3) but failed to notify (S1). (W3) verified she was notified by (S2) of the incident and that (R1) had no major injuries and to monitor (R1’s) condition. When questioned, (W2) states that any impact on the head should be seen by a medical professional and may require further observation along with x-ray scans. (S1-S5) confirmed that no skilled medical professional examine (R1) from 02/20/22 through 03/20/22. (S2) verified that (R1) has a history of falls. The facility eventually had (R1) seen by his primary physician on 03/21/22. Based on information gathered, interviews, service records, and incident reports reviewed, there is sufficient evidence to corroborate the allegation mentioned above. The facility failed to ensure that (R1) was regularly observed for physical changes and that appropriate medical attention was provided promptly. Based on the Department's observation and interviews, records and photographs reviewed, the preponderance of evidence standard has been met, therefore the allegation of "Resident sustained injuries while in care" is found to be: Substantiated . California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D. I NVE STI GATION REVEALED THE FOLLOWING: Allegation: Staff failed to provide adequate transportation for resident. It is alleged that the facility failed to provide transportation to resident #1 (R1) to medical appointments. The complainant states that in November 2021 the facility did not have transportation available for transport (R1) to his medical appointment. The Department reviewed (R1’s) service records and attempted to interview (R1) during the visit and was unable to hold a conversation as a result of his health condition. According to the Admission Agreement regarding transportation to medical and dental appointments, the office staff may assist residents to make medical/dental appointments. The transportation services are available to local medical offices within a 10-mile radius and no staff is available to stay with the resident unless the schedule permits. Interview with staff #1, #6 and #7 (S1, S6, and S7) claims that the family representatives are responsible for making the medical and dental appointments. The appointments have to be scheduled in advance to provide transportation services. The medical/dental appointments scheduled last minute or on the same day will not be a priority and it will be the responsibility of the resident’s representatives to make to make transportation arrangements unless there is a cancellation in the schedule. (S6-S7) verified that there was no request for (R1) in November according to the facility's medical/dental appointment calendar. An interview with staff #1 -#2 (S1-S2) verifies (R1) was being examined by an on-site nurse practitioner witness (W3) and did not have to leave the facility for medical appointments. This was arranged with (R1's) primary insurance and Assisted Living Waiver Program. However, this arrangement came to an end on 02/28/22. Effective 03/01/22, (R1) is now seen by his primary physician. Interviews with residents #1-#6 (R1-R6), and witnesses #1-#6 (W1-W6) did not have issues with medical/dental appointments nor transportation services. Based on information gathered, an inspection of the facility, observation, analysis of (R1's) service records, and interviews conducted, the Department found no evidence to support the allegation “Staff failed to provide adequate transportation for resident." Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Ginger Enriquez and a copy of the report was provided.