complaint·April 25, 2024

The investigation revealed the following: Regarding allegations: resident sustained unexplained injuries while in care and staff did not seek medical assistance for resident in a timely manner, it is alleged that R1 sustained fractured ribs, an injury to the wrist and a minor injury to the toe while in the care of the facility and facility did not seek medical assistance in a timely manner. On 01/04/2022 around 8am, a facility staff became aware of a possible left hand/wrist injury. S3 took a picture of the hand and send it to the Facility Medical Director via text. S3 placed an ice pack on the hand and the Facility Medical Director agreed with that treatment. On the same day around 7:09pm, S4 expressed concerns about the injury to the Facility Medical Director by email. S4 sent the Facility Medical Director the photo from the morning along with a photo recently taken for comparison. S4 inquired about getting an x-ray to rule out fracture because the injury appeared to be worsening compared to the photo taken that morning. Also, R1 was complaining of pain by that evening. However, the Facility Medical Director did not examine the hand or discuss the option of an x-ray with R1’s responsible party until the afternoon of 01/05/2022 at the facility. The Facility Medical Director told R1 that an x-ray could be done at the facility within a few hours. However, R1’s responsible party decided to take R1 to a nearby hospital emergency room but was told that the wait was going to be long and to go back to the facility and call the paramedics to be admitted quicker. R1’s responsible party attempted to do this, but the facility’s Director of Nursing Services told R1’s responsible party that they would not be calling the paramedics and explained that because the hand injury did not appear to be a medical emergency, R1 would still be triage and prioritized at the hospital. After this R1 and R1’s responsible party did not return to the facility and R1 was taken back to R1’s desert home. Eventually R1’s responsible party successfully managed to get the paramedics to take R1 to an emergency room. On 01/06/2022, R1 was diagnosed with three fractured left ribs, a contusion of his left hand and a small toe bruise. A specialist ultimately diagnosed tendon injuries to two of the fingers on his left hand. Though an unwitnessed fall was reported on the evening of 01/04/2022, no one at the facility could explain how R1 sustained these three injuries. On 06/15/2023, this case was referred to a Community Care Licensing Program Clinical Consultant and it was determined that when R1 was admitted to facility, R1 was not identified as a fall risk. However, everything points to resident being a fall risk – R1 had confusion/disorientation, anxiety, used an assistive device (walker) for ambulation, R1 advanced age (93 y/o); and R1 was on psychotropic meds. Despite not having a history of falls, R1 should have been identified as a fall risk, thereby there should have been monitoring to prevent falls/injuries. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining unexplained injuries and facility not seeking medical assistance in a timely manner (refer to LIC 421IM). Exit interview held and a copy of the report and appeal rights was provided. The investigation revealed the following: Regarding allegation: staff did not notify resident's authorized representative of an injury, it is alleged that the facility never called the R1's family to report that the was injury. Interview with S1 revealed that it was S1 along with S2 that called R1's responsible party and left a voicemail. The voicemail they left just stated who they were and where they were calling from and it was regarding R1. They did not want to provide other details due to HIPAA law. R1's responsible party confirmed that the voicemail was received and did not call the facility back because the voicemail did not seem like it was something urgent. Also, R1's responsible party was planning on going the next day to visit R1. IB Investigator obtained a screenshot of the voicemail transcription which is dated 01/04/2022 with a time of 3:33pm which is the same day that R1's injury was discovered. Regarding allegation: resident's hygiene needs were not met, it is alleged that R1 has dirty clothes and nails. Staff interviewed denied the allegation and stated that all resident's hygiene needs are being met. Residents interviewed could not corroborate the allegation and stated their hygiene needs are being met. 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. Exit interview held and a copy of the report was provided