complaint·April 1, 2022

(continued pg 2) In addition, on 3/3/2020 R1 was left unsupervised without the 1:1 private caregiver, nor the alarm floor mat used to prevent falls. IB’ investigation revealed the following: Per IB’s record review: Per A dmission agreement: R1 was admitted to facility 11/23/2019. Per Physician Report dated 11/22/2019 R1 primary diagnosis is Dementia “supervision/ assistance needed” Secondary diagnosis is Frailty: “assistance is needed in walking and transfers and supervision to avoid falls.” Resident is able to transfer to and from bed independently; it is noted that: “needs supervision/ reminders for walker use- to be accompanied by helper, high fall risk.” Per Torrance Memorial Medical Center records: On 1/11/2020 R1 arrived at Torrance Memorial Medical Center (TMMC) at 1717 hours due to a fall and a laceration to the face. A CT scan was done on 1/11/2020 2028 hours which revealed a close heady injury with a small amount of hemorrhage. On 3/4/2020- a CT of the brain/ head without contrast was conducted and it showed a “large left subdural hematoma…”. A consultation states the head CT showed slight increase in Subdural Hematoma. -Per IB interviews: R1 sustained a serious injury from falling, resulting in hospitalization. R1 had arrangements for a one-on-one caregiver from 5:30pm - 1:00am due to resident was a known fall risk. During the evening, on 3/3/2020 R1 was left without adequate supervision. The facility could not find someone to cover the shift and the wellness center staff failed to notify R1’s responsible party. The floor caregiver sat R1 in a recliner inside residents’ bedroom without using available alarm floor mat. R1 got out of the recliner and fell. R1 was down on the floor for an unknown amount of time. R1 was not immediately sent out to the hospital, even though resident had a history of subdural hematoma from a fall suffered on 1/11/2020. LA county fire was dispatched on 3/3/2020 at 2238 hours to Belmont due to a complaint of back pain. On 3/3/2020, according to the medical records; R1 was diagnosed with worsening subdural hematoma likely exacerbated by the fall. Resident had to undergo a craniotomy procedure to evacuate the subdural hematoma. -Per IB Interviews: Resident sustained unexplained injury: On the evening of 3/3/2020 R1 suffered a fall in which the resident was not sent to the hospital. Later that evening R1 fell a second time while a caregiver was assisting resident into wheelchair. R1 sustained an injury to the lower back which resulted in a welt. Facility documentation does show that R1 sustained a skin tear to left forearm and a small bruise on the back. Facility failed to notify residents responsible party about the second fall and unexplained injury to the (continued pg 3) residents back. R1 was eventually sent to the hospital that same evening after the second fall due to R1 complained of hip and lower back pain. -Facility lacked sufficient staffing to meet resident's needs: R1s main private PAL is Staff#1(S1) According to the staff schedule; on March 1 st , 2020 S1 worked from10:30pm - 6:45am. On March 2 nd S1 worked 5:30pm-11pm and then continued the overnight shift into March 3, 2020 watching R1 until 6:45am. According to the staffing schedule, R1 didn’t have a private PAL on March 1 st and March 3 rd between the times; 5:30pm -10:30pm when the fall occurred. On 6/9/2020 Investigator Slatic interviewed Administrator Lamm who disclosed that on 3/3/2020 staff called out sick and it was S2’s responsibility to find Private Pal to cover the 5:30pm -10:30pm shift. Slatic asked if it was facility policy to notify the family when a private PAL cannot be found to cover the 5:30pm -10:30pm shift. Lamm said yes, because this represents an inability by Belmont to carry out the resident’s plan. Lamm had no information to offer that R1s responsible party was notified about the lack of private PAL on the evening of March 3 rd 2020. -Facility failed to ensure safety of resident by not using fall preventive measures ; Per IB investigation; Lamm told investigator Slatic that the use of the floor mat alarm and escort assistance was used to reduce R1’s fall risk. Lamm confirmed that the alarm mat has long cables so it can be moved around the room. Per Investigator Slatic and LPA Cardenas record review; none of the nursing notes or incident report reviewed mentioned the use of the floor mat, or time when the mat was activated and how long it took floor pal to get to it and deactivate it, no indication that the alarm sound is what alerted the caregiver to R1s first fall on 3/3/2020. On 07/27/2020 investigator Sandhu, interviewed S2 who indicated that she believes the floor mat was not utilized by S3 at the time of the incident. -Facility failed to reevaluate resident after falling. Per record review by Slatic; R1 was reassessed on 1/3/2020 and a change of support services needed was required as of 1/3/2020. On 06/09/2020, Slatic interview Lamm; Lamm confirmed R1 had a reassessment on 1/3/2020. Lamm said R1 was not reassessed again for the fall on 1/11/2020 due to it was “very unusual circumstances”. Lamm felt such a fall was unlikely to happen again. Investigator Slatic questioned Lamm about R1s hospitalization from 1/11/2020 to 1/13/2020 and the diagnosis of a subdural hematoma. Slatic asked if upon return from the hospital with such diagnosis, would it have result in change to care? Lamm said yes plan should have been (continued pg 4) updated. Lamm checked computer and said she was dependent on her director of resident care services who is directly responsible for such clinical tasks. Lamm didn’t see anything in her computer to indicate that any updates were made to the care plan. Based on interviews and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. 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 of impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1) Exit interview conducted copy of this report and copy of appeal rights provided to Nina Khatchatrian