complaint·November 4, 2022

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident fell and sustained a fracture Resident fell resulting in multiple injuries. Resident #1 (R1) admitted to the facility on 12/18/19. According to resident #1 (R1’s) Physicians Report, R1 was diagnosed on (05/13/19) with Dementia. While residing at this facility, (R1) had five unwitnessed falls on 07/13/22, 08/20/21, 11/21/21, 02/06/22, and 02/27/22. On 08/20/21, (R1) was admitted to Harbor UCLA Medical Center and suffered from a forehead laceration and nasal fracture. On 02/06/22, (R1) suffered a laceration above the right eyebrow and had blood in the mouth. On 02/27/22, (R1) sustained a laceration to the left eyebrow. On 03/02/22, IB Investigator interviewed Assistant Administrator (S1) regarding the allegations. (S1) stated that (R1) was admitted to the facility in 2019 and suffered from dementia. (S1) stated (R1) had three falls starting sometime in 2021: one in 2021, sometime in 2022, and on 02/27/22. (S1) stated each fall was “unwitnessed”. (S1) stated since the second fall in January 2022, two-hour rounds of monitoring to one-hour rounds of monitoring had been placed since January 2022. (S1) could not explain how (R1) fell the third fall that occurred on 02/27/22. It appears that (R1) was never evaluated by a professional physician regarding his mobility concerns according to (S1). In a statement from (S1), she said she was not present nor had witnessed any of (R1’s) falls in the facility. (S1) stated the residents who have dementia are “locked” in their room to contain them from wandering r or go into other’s resident’s rooms. On 03/09/22, IB Investigator interviewed Administrator (S2). (S2) was unsure of (R1’s) diagnosis when admitted. (S2) described (R1) who is a mobile who liked to “walk and wander” throughout the facility with no supervision. According to (S2), (R1) had five “unwitnessed falls”. These falls occurred on: 07/13/20, 08/20/21, 11/12/21, early 02/22, and late 02/22. (S2) stated he was never a witness to any of these falls and was only notified. (S2) states that based on limited resources (insurance) available for (R1), the facility was not able to provide higher levels of care and supervision to (R1). (S2) unable to answer the question of why dementia residents are locked in rooms. Evaluation Report continues LIC 9099-C On 04/08/22, IB Investigator interviewed staff #3 (S3) med-tech supervisor, staff #4 (S4) Med-tech/caregiver, staff #5 (S5) caregiver, and staff #(S6) caregiver all in the Memory Care Unit. (S3) stated that (R1’s) behaviors changed with “a lot of redirecting” and (R1) required Activities of Daily Living (ADLs) and did not have assistance with any mobile devices. (S3 - S6) recalled (R1) had multiple falls all unwitnessed. (S3) reported, due to multiple falls, (R1) became a “fall risk”. (S3 - S6) mentioned the facility should have increased supervision or given one-on-one care, as that would have prevented the falls. (S3) stated dementia residents’ doors are locked when a resident is in their room. To prevent (R1) from wandering, (S5) claimed (R1's) door was locked and was restrained with a seatbelt. As for (S4 - S6), they reported that dementia residents should not be restricted to any device or locked in an indoor environment. (S4) stated it’s a fire hazard to restrain any residents to their wheelchairs. A review of service records revealed no medical or needs and services assessment performed on (R1) since 2019. The facility did not have a Fall Prevention Plan for (R1). Multiple unwitnessed falls and injuries occurred because the facility did not provide the proper level of care and supervision. Investigator Ryan Miles and Investigator Heidy Bendana observed (R1) was restrained by a blanket tied and knotted around (R1’s) waist while in a wheelchair and was locked in a room on 03/03/22. Based on the Department's observation, interviews, records reviewed and analysis, the preponderance of evidence standard has been met, therefore the allegation of “ Resident fell and sustained a fracture” and “Resident fell resulting in multiple injuries” are found to be: Substantiated . California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” During today’s visit a $500 Civil Penalty is assessed. During today’s visit a $250 Civil Penalty is assessed. An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrator Ginger Enriquez. ACTIONS: · Immediate Civil Penalty CITATIONS: · Administrator Qualification and Duties · Reporting Requirements · Additional Personal Rights of Residents in Privately Operated Facilities · Observation of Resident · Care of Person with Dementia · Postural Support · Personal Right of Resident in All facilities INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility not allowing resident to receive visitors. It’s is alleged the staff is not allowing (R1) to have visitors. The complainant witness #1 (W1) reported a family member of (R1) was not allowed visitations. The complainant claims staff # 3 (S3) stated the facility stopped visitation two months ago due to COVID. The Department reached out to the family member witness #2 (W2) who was not available for comment. (S1 and S3) claims due to COVID-19 and the measures set in place by Community Care Licensing, The Department of Public Health and Centers for Disease Control and Prevention mandated additional steps to ensure the health and safety of residents and staff from outside contact resulting in many cases suspending in-person face to face visitation, except when medically necessary to the care of the resident. Such as home health, hospice care, and end of life. (S1) states that the health and safety of residents and staff are of utmost importance, but also considers all the resident’s rights as well. According to (S1 and S3), (R1) was allowed visitors even from November 2021 through February 2022 when the facility had a surge of COVID activity throughout the facility after the holiday season. Visitors were allowed an in-person to visit through a window from a vacant room. (S3) claims room #17 was the designated room used for residents in Memory Care. All visitors had to sign in through the front and they could visit through the window and remain safe for all parties. The Department is unable to gather information related to this allegation due to (R1’s) medical condition. Interviews with residents #2-#10 (R2-R10) stated they had no issues related to visitations. (R2-R10) reported the facility was accommodating with visitations during the COVID pandemic. Based on the Department’s observation, interviews, and a review of records that were conducted, the Department found there is no evidence to support the allegation mentioned above. Based on information gathered, the Department did not find sufficient evidence to support the allegation: “Facility not allowing resident to receive visitors”. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged allegation is valid did or did not occur. Therefore, the allegation is "unsubstantiated.” An exit interview conducted with Ginger Enriquez, and a hard copy was provided.