complaint·May 15, 2024

Investigation Revealed the Following: Allegation: Resident fell and sustained a fracture due to staff neglect. The details of the complaint alleged that a resident sustained fracture due to facility staff neglect. On 11/6/23, complaint was accepted by IB for a full investigation and assigned to Special Investigator Lorraine Patterson. As part of the investigation, investigator Patterson obtained the (R#1)’s facility file, (R#1)’s medical records from Centinela Hospital, (R#1)’s interview, facility staff interview(S#1-S#2), witnesses’ interviews(W#1-W#2), facility administrator interview(A#1) and an Attempted contact with Reporting Party (RP) Investigator Patterson conducted the following based on interviews. On 12/11/23, Investigator Patterson spoke with Administrator (A#1), she stated that she does not suspect any neglect which led to (R#1)'s fall and subsequent fracture while in care. She maintained that during the time of their back-to-back falls on 05/2/23 and 05/03/23, they were medically and physically stable, and there was no change in their baseline that contributed to their fall. According to her, (R#1) was able to "push" themselves around and ambulate in their wheelchair while in care. (R#1) could call for help and make their needs known. On 12/11/24, Investigator Patterson spoke with facility staff (S#1 and S#2), (2) out of (2) denied neglect/lack of supervision and care contributed to (R#1)’s falls that lead to (R#1)’ fractures. On 12/11/24, Investigator Patterson spoke with residents in care (R#2 and R#3), (2) out of (2) state that they denied suspecting and or witnessing neglect from facility staff contributed to (R#1)’s falling sustaining a fracture or injury. Evaluation Report continues LIC 9099-C On 1/17/2024 Investigator Patterson arrived unannounced at Hawthorne Convalescent Home Center to conduct an in-person interview with (R#1). (R#1) confirmed while they lived in care at Hawthorne Terrace Care Home, they sustained two falls (05/02/23; 5/03/23). (R#1) told investigator during their first fall they “slipped” while reaching for a paper because they had an appointment with the doctor that day and they needed to call transportation to pick them up. (R#1) stated that their first fall they injured their nose. (R#1) told investigator during his second fall that the “same” thing happened. (R#1) stated they “reached” for a potato chip on the floor and slipped out of his wheelchair. (R#1) told investigator during their second fall they sustained a broken hip. (R#1) denied neglect and or physical abuse that led/contributed to their fall sustaining a hip fracture. (R#1) told investigator after both falls 911 was called and they were taken right away to the hospital. (R#1) admitted facility staff instructed them to ask for help but they did not follow instructions. The review of the Centinela Medical Center (#M000233890) dated 5/3/2023 revealed that (R#1) was admitted through the emergency room and the reason for the visit was right hip pain. The Chief Complaint stated that (R#1) had a mechanical fall from a wheelchair prior to their arrival while reaching for trash on the ground. (R#1) fell out of the wheelchair on their right side. (R#1) reached for something while in his wheelchair and fell. The Hospital Summary Report stated No suspected abuse. The Discharge Summary/Diagnosis stated: Neglect/Abuse Screening: None. Social Services Issues: None. Hip fracture, status post open reduction internal fixation. Discharge on 5/9/23. Evaluation Report continues LIC 9099-C Allegation: Facility staff did not provide an adequate quantity of food to resident. The details of the complaint alleged that facility staff did not provide an adequate quantity of food to residents. During the physical tour of the facility's kitchen and food pantry, LPA observed an abundance of perishable and non-perishable food available for residents in care, as well as a 7-day food supply for emergencies. During an interview with the administrator (A#1), she stated that the facility serves three meals per day to the residents: breakfast, lunch, and dinner, along with two snacks. Ambulatory residents are also able to help themselves to snacks in the kitchen. Additionally, when it comes to serving well-balanced and nutritious meals, (A#1) stated, "Yes, we serve good meals to residents. We provide protein, vegetables, and carbohydrates in every meal." Furthermore, (A#1) states that the facility has enough perishable and non-perishable food for residents in care, ensuring that residents do not go to bed hungry. During interviews with residents (R#1-R#7), (5) out of (7) stated that the facility offers them three meals per day plus snacks. They mentioned that the facility provides well-balanced and nutritious meals consisting of protein, vegetables, and carbohydrates. Additionally, (5) out of (7) residents stated that the facility has enough food for them and the rest of the residents in care, and they have never gone to bed hungry. During interviews with staff (S#1-S#2), both staff members stated that the facility offers three meals per day to residents in care: breakfast, lunch, and dinner, as well as snacks between meals. Additionally, both staff members stated that the residents receive well-balanced and nutritious meals that include protein, vegetables, and carbohydrates. They also mentioned that the facility has enough food available for all residents in care. Furthermore, both staff members stated that the residents do not go to bed hungry . Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the Complaint Report was given to Josephine Hauf /Administrator.