Incident investigation·March 29, 2023

On 03/29/23, Licensing Program Analyst (LPA) Wendy Gibbs, conducted a Case Management visit in regards to an incident report that happened to Resident #1 (R1) and was received via fax to CCL on 03/20/23. LPA met with Administrator Sandra Lopez and explained the purpose of todays visit. During todays’ visit, LPA and Administrator toured the facility. LPA reviewed the file for R1, and hospital discharge papers. LPA interviewed the Administrator. Per Administrator, on 03/19/23, R1 was found by staff on the ground on the smoking patio. Staff helped R1 up and R1 complained of pain on the elbow. When staff questioned R1 about what happened, R1 stated they slipped off their wheelchair and bumped their elbow and the corner of their right eye. Staff called emergency personnel immediately to be checked out. Upon x-rays, R1 was diagnosed with a fractured elbow. R1 was discharged and returned to facility on the same day. On 03/20/23, Primary Care Physician, Dr. Golchini, requested R1 be transferred to Los Angeles Downtown Medical Center for physical therapy due to generalized weakness and recent falls. LPA’s received physicians report, hospital discharge papers and needs and services. No deficiencies were cited at this time. An exit interview was conducted and a copy of this report was provided to Administrator Sandra Lopez