Complaint·November 2, 2024

This complaint report supersedes the report completed on 7/19/24. Investigation Revealed the Following: Allegation: Resident lost part of his finger and a laceration under eye while in care due to an unwitnessed fall. This complaint alleges the facility provided insufficient supervision for Resident # 1 (R1). The lack of supervision resulted in R1 sustaining a left finger injury and a laceration under the eye as a result of an unwitnessed fall. The department interviews with Resident (R1), Staff (S1), House Manager/ Crystal Adams (S2), and Administrator/Ronic Tatum (A1), indicate the following: On 03/01/22 2:40 PM, staff #1 (S1) stated she assisted R1 in R1’s wheelchair to R1’s bed for a nap. S1 then went to the kitchen. S1 stated approximately twenty minutes later, she heard a “thump” noise in R1’s room and went to check on R1. S1 stated she observed R1 had fallen and was on the floor near R1’s bed. S1 stated she observed R1’s hand was bleeding. S1 stated she then observed an injury on the dip to the tip of R1’s left 5 th finger had sustained an avulsion injury and part of R1’s finger pad torn off. S1 stated she also observed a laceration under R1’s left eye.S1 stated she found the skin torn off of R1’s finger on the floor. S1 placed the skin in a bag and on ice to be taken to the hospital with R1. S1 stated R1 is a fall risk. The department conducted an interview with S2, who stated that on 03/01/2022, she left the facility to run errands when the incident occurred and was not present when R1 sustained injuries. The department conducted an interview with A1 who confirmed S1 was working when R1 fell; however, she was unable to confirm any additional staff members were working when the incident occurred. A1 reported the facility census is (6) Residents. R1’s Family Member (W1) was contacted after the incident occurred and W1 transported R1 to Kaiser Permanente West Los Angeles Medical Center Urgent Care. Evaluation Report continues LIC 9099-C... This complaint report supersedes the report completed on 7/19/24. The department found the facilities staffing was insufficient when this incident occurred as S1 was the only staff member working with (6) Residents when R1 fell and sustained significant injuries. The preponderance standard has been met; therefore, the allegation is substantiated. Deficiencies are being cited an the LIC9099-D. An immediate civil penalty of $500 is warranted accordance with California Health and Safety Code. See LIC421IM. Currently an enhanced civil Penalty determination is pending. Exit interview was conducted and plan of correction was developed with the Administrator. A copy of this report and Appeals Rights was provided to Pam Speights/Facility Staff.