complaint·March 3, 2023

A separate investigation was conducted by the Department of Social Services, Investigator Lorraine Patterson that included a review of hospital medical records, interview with witness, facility staff, and facility residents. INVESTIGATION REVEALED THE FOLLOWING: Allegation #1 : this investigation revealed that Resident #1 (R1) on 05/08/22 was taken by Emergency Medical Services to Harbor UCLA Medical Center due to sustaining an unwitnessed fall. At the hospital, (R1) was found with a right frontal hematoma. Images of Computed Tomography (CT) revealed a large left hemispheric subdural hemorrhage. Medical reports revealed it was uncertain if (R1’s) fall was due to an abstract fall or a loss of consciousness for short period. The abuse screen revealed elder/dependent abuse present was “no”. (R1’s) subdural hematoma was managed conservatively and was discharged back to care at this facility on 05/14/22. The reporting party/witness #1 (W1) denied neglect or abuse led to (R1’s) fall and added that (R1) was not a fall risk. (R1) did not have a history of falls from a prior residential care facility. However, (W1) remained concerned that (R1) had limited exercise at this facility. The investigator was informed by (W1) and (S1) that (S1) provided care to (R1) minutes before (R1) fell. (S1) denied neglect or abuse and insisted (R1) did not have a history of falling, and that (R1) was at baseline when the unforeseen fall happened. Records reviewed and interviews witness, care staff and residents interviews did not corroborate the allegation of neglect or elder abuse led to (R1) sustaining an injury in care. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: “Resident sustained an injury while in care” is unsubstantiated . A separate investigation was conducted by the Department of Social Services, Investigator Lorraine Patterson that included a review of hospital medical records, interview with witness, facility staff, and facility residents. INVESTIGATION REVEALED THE FOLLOWING: Allegation #3 : this investigation revealed (S1) admitted on 05/08/22 when he discovered (R1) sustained an unwitnessed fall resulting in an injury, (S1) telephone the (W1) of his observations before calling Emergency Medical Services (EMS). (S1) further admitted that on 05/23/23 during (W1’s) visit, (S1) was put on noticed about (R1) not moving the right arm. (S1) admitted (EMS) was not contacted until (W1) left the facility and returned with a family to further assess (R1’s) condition. Based on records reviewed and interviews conducted with witness and care staff did revealed evidence to corroborate neglect/failure to seek timely medical attention. Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/FAILURE TO SEEK TIMELY MEDICAL ATTENTION: “Facility staff did not seek out timely medical attention for resident in care” is substantiated . According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099-D).