complaint·June 4, 2021

The investigation revealed that R#1 had a history of falls prior to being admitted to the facility on 03/20/17. R#1 was assessed by the facility on several occasion and determined was diagnosed with dementia, was a fall risk and in need of additional supervision due to wandering and being a fall risk as supported by the following documents; 03/20/17 - Functional Capability Assessment, Preplacement Appraisal, R#1 Head to Toe Assessment. R#1 Appraisal/Needs and Services Plan dated 04/27/17 indicated that R#1 has a history of falls and previous injury while residing at different facility, R#1 Assessment Tool dated 11/07/07 indicated R#1 required supervision when Resident #1 moved about the facility and was deemed to be “non-ambulatory. R#1 Physician’s Report dated 03/22/18 indicated R#1 was deemed to be “confused” and “disoriented,” and engaged in “wandering behavior.” R#1’s Individual Service Plan’s (ISP) dated 05/8/18, 11/27/18, 07/30/18 indicated R#1 is at risk for falls and potential for injury due to difficult walking, muscle weakness. At risk for musculoskeletal deconditioning, muscle atrophy and generalized weakness r/t patient’s decreased functional mobility and 02/14/19 - Appraisal/Needs and Services Plan documented that R#1’s doctor ordered a wheelchair, but R#1 refused it. The investigation revealed R#1 fell or was found on the floor after a fall while residing in the facility on three separate occasions in the month of June 2019 as evidenced by incidents that occurred on 06/05/19, 06/22/19 and 06/27/19. Per the 06/27/19 incident, R#1 was observe by staff #1 falling while watching the surveillance monitor and went to assist R#1 and 911 was called. Paramedics took R#1 to the hospital for treatment due to R#1 being in pain after the fall. Per the hospital records dated 06/27/20, R#1 was seen for the 06/27/19 fall and X Ray revealed R#1 sustained fractures of the left clavicle and a right hip fracture. On 06/22/21, R#1 fell in the facility, however, R#1 was not taken to the hospital for evaluation as R#1 did not have any signs or symptoms of pain and denied pain for the 06/22/19 incident report. Therefore, the facility was aware that R#1 has fallen in the facility three time in less than a thirty day period and had ample notice that R#1 required more care and supervision and develop a care plan of care to assist R#1 with her needs for assistance with wandering, falls while ambulating, however the facility neglected to develop a care plan to assist R#1 with adequate supervision due to wandering and being a fall risk, which resulted in R#1 falling three times in the facility in June 2019 and sustained a fracture of the left clavicle and right femoral neck (Right Hip). Continue to LIC9099C.... In regards to the allegation: Staff did not follow up on obtaining doctor’s orders for resident medication which led to fall. The Department’s investigation consisted of interviews with resident #1 And staff #1 - #17. Review of resident #1 facility file and medical reports. The investigation revealed that R#1 had a history of falls prior to being admitted to the facility on 03/20/17. R#1 Functional Capabilities Assessment upon being admitted to the facility indicated R#1 was able to walk and transfer from bed with out assistance and would require grab bars and assistance with activities of daily living (ADLs). R#1 medication charted for May 2019 indicated R#1 was prescribed a medication on 02/19/19. Staff assisted with dispensing medication until 05/14/19 when it was discontinued by a physician. On 05/10/19 the facility received a faxed written prescription for a 30-Day supply of “Prednisone”. On 05/14/19, the facility received handwritten note indicating the medication was discharged. R#1’s June MARs listed Prednisone amongst R#1 medications. On 06/27/19, R#1 was given a new written order for a 90-Day supply of “Prednisone” which was filled by the pharmacy on 06/27/19. During the Month of June 2019, R#1 had three separate incidents, (06/05/19, 06/22/19 and 06/27/19) where R#1 was found on the floor or fell in the facility. Therefore, the facility failed to follow up with R#1 physician regarding residents falls and securing the R#1 medication Prednisone, which R#1 relied on to relieve muscle pain and stiffness. R#1 medical records indicated that R#1 medication Prednisone was discontinued and R#1 had greater difficulty ambulating. Had R#1 received the physical therapy that doctor ordered, received stand-by assistance while ambulating, been reminded by staff to use a walker and been afforded anti-inflammatory medication, R#1 would not have experienced such frequent falls. An immediate Civil Penalty was issued in the amount of $500 for lack of care, which resulted in R#1 receiving medical treatment due to sustaining an injury. Deficiency was cited on LIC809D. "The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e) or (f), or 1548 (e) or (f) , 1568.0822(e) or (f)." Based on the department's observations, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted and copy of this report and appeal rights provided to Melissa Flores. In regards to the allegation: Staff did not obtain medical care for resident in a timely manner. On 06/22/19, during an evening room check, staff#1 found R#1 on the floor of resident room, however, R#1 was not evaluated by a medical professional for injury, because it was unclear whether R#1 had fallen, despite the facility policy that an unwitnessed fall of a resident with dementia would always result in medical evaluation. During the 06/22/21 assessment of R#1, staff #1 assessed R#1 extremities for range of motion and observed no indication of R#1 experiencing pain. However, Staff #2 informed the Department that R#1 did in fact verbalize pain during the 06/22/19 assessment. When Resident #1 was seen at the hospital on 06/26/19 for an unrelated evaluation, R#1 complained of extreme pain to the upper left arm and dark bruising was observed. R#1 facility records nor staff member statements noted R#1 to be in any pain between 06/22/2019 and 06/26/2019, but R#1 bruising on the left arm and shoulder would have been readily apparent when caregivers assisted R#1 with getting dressed and other activities of daily living and R#1 was to receive stand-by assistance when ambulating. On 06/27/19, R#1 was examined at the hospital due to a fall in the facility that morning and R#1 X-Rays revealed R#1 left clavicle fracture and X Rays taken at a different hospital on 06/26/2019 also showed R#1 to have a fractured left clavicle. Therefore, had the facility arranged for R#1 to be medically evaluated after R#1 was found on the floor on 06/22/2019 or when the bruising to R#1’s arm first became apparent, R#1 could have been provided with medical treatment for R#1 injury at an earlier time. The investigation revealed, on 06/22/19, staff #1 found R#1 on the floor of resident room and the facility failed to obtain timely medical treatment. The facility did not seek medical treatment immediately after the 06/22/19 incident and waited for several days to have R#1 evaluated by a medical professional, R#1 was seen by a medical professional on 06/26/19 for an unrelated condition and seen on 06/27/19 after falling again in the facility. R#1 X Ray’s dated 06/26/19 and 06/27/19 revealed R#1 sustained a fractured left clavicle and a fracture right hip. Continue to LIC9099C....