complaint·October 25, 2024

Record reviews revealed the following: Resident records indicate that R1 requires assistance in transferring from chair to bed and has risks of falls. Incident reports indicate that on 08/12/22 around 2:15 PM an agency caregiver helped R1 transfer from R1’s wheelchair to the bed when R1 fell. R1 indicated that during the incident the "small lady" caregiver who was assisting R1 could not support R1’s weight, R1 lost balance, and fell during the process. The incident report revealed that Resident #2 (R2) witnessed the fall and indicated the caregiver tried to help R1 by moving R1's foot that would not move. Without supporting R1's balance, when R1's foot was pulled forward, R1 fell down. Hospital medical records indicate that on 08/13/2022, R1 was hospitalized at St. Mary’s Medical Center and during R1’s evaluation, it was discovered R1 had fractured her leg in two different places which required surgery. Interviews revealed the following: Staff indicated that the caregiver who assisted R1 during the fall was employed with an outside agency. Two out of four residents indicated they have witnessed staff struggle with residents who need transfer assistance. One out of the two residents indicated that they have fallen a couple of times while in care at the facility. Regarding the allegation “Resident sustained fractures due to staff dropping resident while transferring,” based on record reviews and interviews, the preponderance of evidence has been met therefore the allegation is 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 anybody member or organ, a wound requiring extensive suturing, and serious disfigurement.” An exit interview was conducted and a copy of this report and appeal rights was provided to with Executive Director Michael Mendoza.