Complaint·September 12, 2023

Allegation 1 : Resident sustained unexplained fractures while in care. It is alleged that Resident #1 (R1) sustained unexplained fractures while in care. Reporting Party (RP) reported R1 was admitted to Torrance Memorial Hospital on 9/16/2020 and the x-ray result shows R1 had two broken ribs. IB Investigator Kujawa interviewed the Administrator (S1) and a Witness: R1’s family (W1). Investigator Kujawa was unsuccessful in his attempts to interview the two caregivers (S2 & S3) who were present during the incident. During the attempts by Investigator Kujawa to interview the two (2) caregivers, S2 was out of the country and S3 was no longer employed with the facility. Investigator Kujawa attempted to interview R1 (the victim); but due to medical conditions, a proper interview was not accomplished. Investigator’s interview with S1 revealed S2 witnessed R1 slide/fall out of the chair and onto the floor. S2 called S3 to assist with picking up R1 off the floor. S2 and S3 asked R1 if the resident had any pain and R1 denied pain. S1 stated both caregivers (S2 and S3) examined R1 and found no evidence of pain or injury. S1 admitted that S2 and S3 are not medical professionals and do not have medical training; but, S1 revealed that R1 was not taken to the doctor for an examination. S1 claims they did not know about R1’s fall until R1’s son notified S1 (by telephone) that R1 had suffered two (2) fractured ribs. Interview conducted of S3 by RA Ceniceros (via landline) on 08/17/23 corroborated that facility staff did not witness R1 slip and fall on 09/12/20. Based on records review, the hospital discharge summary documented that R1 was admitted to the hospital on 9/16/2020 at 13:40 hours with a diagnosis of “Fall” and “Multiple fractures of ribs of the right side”. R1’s Computed Tomography (CT) Chest Scan revealed right-sided fractures of the eighth and ninth ribs. R1 was discharged from the hospital on 09/18/2020 without any complaints. Based on records review and interviews, there is no sufficient evidence to corroborate the above-mentioned allegation. 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 of Neglect/Lack of Supervision: “Resident sustained unexplained fractures while in care” is found to be UNSUBSTANTIATED. Evaluation Report Continues on LIC 9099C... Allegation #2 : Resident was left on the floor for a long period of time. It is alleged that Resident #1 (R1) was left on the floor for a long period of time. Reporting Party (RP) reported that R1 told the RP that they fell during the night on the floor and they were calling for help for a long time. Based on records review, the Unusual Incident/Injury Report indicates on 09/12/2020, R1 slipped off the chair while sitting. Both Staff (S2 and S3) picked up R1 from the floor. IB Investigator Kujawa interviewed the Administrator (S1) and a Witness: R1’s family (W1). Investigator Kujawa was unsuccessful in his attempts to interview the two (2) caregivers (S2 & S3) who were present during the incident. During these attempts by Investigator Kujawa of interviewing the two (2) caregivers, it was learned that S2 was out of the country and S3 was no longer employed with the facility. Investigator Kujawa attempted to interview R1 (the victim), but due to medical conditions, a proper interview was not accomplished. Based on Investigator Kujawa’s interview with S1 on 12/16/2020, S2 witnessed R1 slide/fall out of their chair and onto the floor, S2 called S3 for assistance to pick up R1 off the floor and place the resident onto their bed. Both S2 and S3 checked R1 and found no indication of injury or bruises. On 12/15/2020, Investigator Kujawa interviewed W1 who admitted there were no similar prior issues with the facility and the facility has been great to both for many years. W1 revealed due to R1’s medical conditions, it is difficult to understand the resident, but W1 admitted that R1 is now doing well. Interview conducted of S3 (via landline) by RA Ceniceros on 08/17/23 corroborated that facility staff had not left R1 on the floor for a long period of time following a slip and fall on 09/12/20. Based on records review and interviews, there is no sufficient evidence to corroborate that R1 was left on the floor for a long period of time. 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 of Neglect/Lack of Supervision: “Resident was left on the floor for a long period of time” is found to be UNSUBSTANTIATED. Exit interview conducted and a copy of the Complaint Report was issued and discussed with Licensee/Administrator Joel Morales/Administrator.