complaint·June 1, 2024

LPA Randle requested and obtained copies of the following documents: Staff Work Schedule & Roster (dated 07/11/23), Resident Roster (dated 07/11/23), Pre-placement Appraisal Information (dated 04/11/23), Admission Agreement (dated 04/22/23), Appraisal/Needs and Services Plan (dated 04/22/23), Physician’s Report (dated 03/30/23), Progress Notes (dated 07/20/23 to 04/22/23), Initial Evaluation Results (dated 04/22/23), Capability Evaluation Report (dated 04/22/23), and Unusual Incident Reports (dated 04/25/23, 05/22/23, 06/05/23, 06/19/23, 06/30/23, 07/02/23, 07/11/23, 07/13/23, 07/16/23, 07/17/23). This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and assigned to Investigator Dennis Douglas. The investigation included a review of medical records from Torrance Memorial Medical Center (dated 04/25/23, 06/19/23, 06/30/23) and Harbor-UCLA Medical Center (dated 04/25/23, 07/16/23, 07/17/23; interviews were conducted of Facility Staff #S1 – #S5, Resident #1, and Witness #1. INVESTIGATION REVEALED THE FOLLOWING: Regarding Allegation #1 : this investigation revealed that Resident #1 moved into the facility on 04/22/23. On 04/25/23 at 8:52 a.m., Resident #1 was outside of the community and had fallen while on a walk. A female passerby observed the resident and called 9-1-1. Resident #1 was transported to Torrance Memorial Hospital ER and diagnosed with a fracture to the right, upper arm due to the fall. That same day, Resident #1 returned to the facility at 3:00 p.m. and was sent back out to Harbor UCLA Medical Center due to being unresponsive. On 05/22/23 at 9:36 a.m., Resident #1 sustained a fall and was found on their right knee on the floor holding on to their walker – no injuries or hospital transport. On 06/05/23 at 2:05 p.m., Resident #1 was observed on the floor (in front of their apartment door) and had fallen on their right knee and was unable to get back up. Resident #1 sustained a skin tear to their right knee and elbow – no hospital transport. On 06/19/23 at 5:30 a.m., Resident #1 was found (on their bed) in a pool of blood by Staff #6 and Staff #7 and 9-1-1 was summoned and the resident was transported to Torrance Memorial Hospital Emergency Room (ER). On 06/30/23 at 9:20 a.m., Staff #4 responded to Resident #1’s pendant alarm. Resident #1 was found lying on their right side (on the fractured right arm) with a skin tear to the right knee. Facility staff called 9-1-1 and the resident was transported to Torrance Memorial Hospital ER. On 07/02/23 at 6:09 a.m., Staff #9 responded to Resident #1’s pendant alarm and found the resident (on the floor) lying on their back. Staff #9 responded and assessed the resident. (Evaluation Report continues LIC 9099-C) Facility staff summoned 9-1-1 as a precaution and paramedics arrived at 6:20 p.m. to assess the resident and their vitals were normal and no head injury – no hospital transport. On 07/11/23 at 2:40 p.m., Resident #1 was walking to the Bistro area and walked too fast (with their wheelchair) and fell on their left knee. Resident #1 was found on the floor by Staff #5 who assisted the resident back up. Resident #1 sustained a skin tear to their left knee – first aid was applied and no hospital transport. On 07/16/23 at 9:15 a.m., Resident #1 was found on the floor (near the closet) lying on their back and bleeding from the forehead. Facility staff summoned 9-1-1 and the resident was transported to Harbor-UCLA Medical Center. On 07/17/23 at 11:00 a.m., Resident #1 was found by Staff #12 lying on the floor (on their back) in the kitchen area (in front of the sink) in their apartment. Resident #1 sustained skin tears to their right elbow, right knee, left elbow, left knee; and old wounds opened: right elbow, right knee; and, a new wound from the forehead. Facility staff summoned 9-1-1 and the resident was transported to Torrance Memorial Hospital ER. During the course of this investigation, it was revealed that Resident #1 sustained several unwitnessed falls during their residency at the facility. (Physician’s Report documented under “ Capacity for Self-Care ” able to care for self without assistance; under “ Physical Health Status ” motor impairment/paralysis: mild mobility issues, mild muscular stiffness, and mild difficulty getting up from chair or bed but independent and not a fall risk; under “ Mental Condition ” able to leave facility unassisted; under “ Ambulatory Status ” this person is able to independently transfer to and from bed). As a result of Resident #1’s initial fall (outside the facility), the resident sustained a broken clavicle; in which, the resident was transported to Torrance Memorial Hospital. It was disclosed that once Resident #1 was discharged back to the facility on 06/30/23, the resident was no longer independent and required assistance by facility staff. It was revealed that Resident #1 was issued a pendant alarm to summon staff whenever the resident required assistance, a pull cord was also installed next to the resident’s bed in case of an emergency, and reminders were made to Resident #1 to wear their grip socks using their walker and whenever the resident is moving around in their apartment. Based on the evidence gathered and interviews conducted, and records reviewed, 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 a fracture while in care is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to the Resident Care Director (Yvette Lem).