Complaint·July 19, 2024

Regarding the allegation: “Resident lost part of his finger while in care.” It is being alleged that staff do not supervise residents resulting to resident getting injured while in care. IB interviews indicate the following: The administrator stated that on 03/01/2022 she was not present at the facility and the incident happened during a short 30-minute period when there were no other caregivers were present at the facility other than S1. Staff (S1) S1 stated that on 03/01/2022 around 2:40 pm S1 just laid R1 to bed for a nap and went to the kitchen to prepare dinner. After 20 minutes S1 heard a bump, she got to R1 room R1 was on the floor by the bed, and S1 discovered R1 left finger was bleeding and pieces of the skin was on the floor. R1 suffers from dementia and does not recall how they lost part their finger. R1 was transported to Kaiser Urgent Care and was treated for an injury sustained on the left hand. Record Reviews indicate the following: R1 Physician’s Report dated 01/18/2022 indicate that R1 is confused, is disoriented, has inappropriate a nd wandering behaviors. Hospital Medical Records indicate that R1’s injury to the left finger was a tear of the skin from the fingerprint to the tip of finger (tears typically caused by explosions, gunshots, and animal bites and industrial equipment injuries.) The medical records and the explanation provided by the facility staff on how they believe R1 sustained the injury was not consistent with the diagnosis provided by medical staff on how R1 got injured. The preponderance standard has been met, therefore, the allegation “Resident lost part of his left finger while in care” is substantiated. California Code of Regulations, Tittle 22, Division 6, and Chapter 8 are being cited. Please see LIC9099D. Exit interview was conducted and plan of correction was developed with the Administrator. A copy of this report and Appeals Rights was provided . Regarding the allegation: Resident has a laceration under the eye. It is being alleged that residents are being physically abused while in care. IB Interviews indicate the following: Staff S1 stated that on 03/01/2022 around 2:40 pm that S1 just laid resident R1 to bed for a nap and went to the kitchen to prepare dinner. After 20 minutes S1 heard a bump, when S1 got to R1’s room R1 was on the floor by the bed and discovered R1 has a laceration under the left eye. Then S1 contacted the administrator and informed her about what happened, she instructed S1 to take R1 to Kaiser Urgent Care. R1 suffers from dementia and does not recall anything that happened or how R1 sustained a laceration under the left eye. The administrator and staff all stated that they checked for objects that could possibly cause the laceration under R1’s left eye. There were none observed. 2 out of 2 residents did not disclose any physical abuse by staff members or experiencing any abuse themselves. Record reviews indicate the following: Hospital medical records obtained during the investigation; notes that the laceration near left eye is a healing wound. Based on IB, interviews, records reviews, and medical information available there was not enough evidence to support the allegation. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted. A copy of the report was provided to the Administrator Krystal Adams.