complaint·September 14, 2022

Regarding Allegation Resident sustained multiple injuries while in care : Resident #1 was admitted to the facility on 07/24/21. According to R1 Physicians Report R1 was diagnosed (as of 07/21/21) Dementia, Vascular Dementia, History of Stroke, Type II Diabetes, Hypertension, Coronary Artery Disease (CAD) , Lumbar spinal stenosis and Chronic Kidney Disease (CKD). During R1 residing at Palmcrest Grand R1 had 2 falls. On 10/28/2021, Resident #1 (R1) was admitted to College Medical Center for a mechanical fall in the shower at Palmcrest Grand Residence. During evaluation, R1 suffered a closed fracture in one rib, and fracture of transverse process of thoracic vertebra. On 10/29/22, R1 was re-admitted to hospital at Kaiser South Bay Medical Center with a chief complaint of a Fall last night and Rib Pain. R1 was diagnosed with mechanical fall with left 6th posteriorly rib fracture and T7 left transverse process fracture and CT R frontal hematoma. On 11/02/21 R1 was discharged from Kaiser South Bay Medical Center with home health services. On 11/04/21 R1 sustained a second fall and was admitted to Long Beach Memorial on 11/04/21 with a subdural hematoma (brain bleed) due to unwitnessed fall from resident’s bed, to the ground – in a supine position. Resident #1 was not discharged back to Palmcrest Grand Residence. On 1/5/2022, IB Investigator interviewed Peggy Clark Administrator (S1) regarding the allegation. S1 stated R1 was admitted to the facility July 2021. S1 stated R1 sustained two falls in the facility, first fall October 2021 and the second November 2021. S1 stated after R1 first fall the LVN did not reassess R1 but did increase R1 Safety checks to every 30 minutes as the resident became a fall risk. On 1/5/22, IB Investigator interviewed Veronica Gomez Assistant Administrator (S2) regarding R1. S2 stated R1 was admitted to the facility around August 2021 and assessed with Vascular Dementia and placed in the Memory Care Unit. S2 stated R1 health began to decline, such as, loss of appetite. When R1 did not eat, R1 would feel dizzy, lose balance and has incurred a fall(s). S2 stated after R1 first fall R1 was reassessed and frequency of room checks for R1 was increased to every 15-30minutes. At the same time S2 stated their were 6 other residents in Memory Care Unit that required increased supervision. S2 stated the facility should have provided R1 one-on-one supervision or increase R1 level of care” after R1 first fall, “knowing” that R1 became a fall risk. IB investigator interviewed S3-S4. S3 stated R1 did sustain injuries from 2 falls at the facility. S3 stated R1 health had been declining and R1 should have been in a higher level of care. S4 stated the facility knew R1 was fall risk and should have increase R1 care and supervision to possibly a one to one. S4 stated S4 believes R1 needed a higher level of care. LPA reviewed R1 records and did not observe a reappraisal or reassessment of R1 documented following R1 falls. IB investigator/ LPA interviewed Witness (W1) that stated that R1 quality of life changed after the second fall resulting in R1 no longer being able to feed herself, balance, speak coherently and walk without extreme assistance. W1 stated following the first fall Palmcrest Grand had assured they could provide proper care to R1. W1 stated R1 passed away 5 months following the second fall.Based on records reviews and interviews conducted the facility failed to reassess R1 when it was observed R1 had changes in care needs resulting in R1 having falls and sustaining serious injuries from falls. Based on interviews and observations and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained multiple injuries while in care is found to be SUBSTANTIATED. 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 or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” During today’s visit a $500 dollar Civil Penalty is assessed. An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrator Peggy Clark. Regarding Allegation Resident sustained unexplained bruising : investigation revealed that Resident #1 sustained bruising to both wrists that was observed by the Witness (W1) during a visit to the facility on 08/21/21. A review of the facility’s Nurse’s Notes entitled, “Resident Body Check” (dated 08/21/21) documented Staff #3 evaluated the resident’s bruising and found no open wounds or skin tears nor bruises painful to the touch. In addition, S3 conducted a resident body check. S3 confirmed that the medication (Clopidogrel 75 mg Tab - commonly known as Plavix) due to resident’s history of stroke could possibly have a side effect as well. The medication works as a blood thinner by increasing the blood flow to the heart; and, it could cause bruising easily. S3 indicated that she continued to follow up with Resident #1 to see if the minor bruising worsened; but it got better. Interview with Administrator Clark confirmed that an Unusual Injury/Incident Report was not completed and submitted to CCLD. Based on interviews and observations and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained unexplained bruising while in care is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to Administrator Peggy Clark.