complaint·September 1, 2021

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident sustained an injury from a fall while in care The complainant alleges that on 8/21/2021 R1 was found on bathroom floor and received an injury due to a fall. LPA Cifuentes reviewed incident report sent by facility for date 8/20/2021, that was faxed to Community Care Licensing. The report states that R1 was in bathroom with S1, when R1 called S1 to let them know something was occurring as they were voiding. S1 turned around to assist R1. Per incident report, R1 did not fall while in bathroom. LPA interviewed staff (S1) who was on shift the evening of the incident. Per S1, R1 did not fall, they were escorted to the bathroom by staff, who turned to give R1 privacy. R1 told S1 that something was wrong, so S1 immediately turned and took note of the situation and called 911. At no time during incident did R1 fall. Reporting parties’ statement is inconsistent with what was reported by S1 during interview as well as report on incident provided by facility to Community Care Licensing. LPA interviewed resident R1, who stated they had fallen but it was a long time ago. Interviews with administrator and S2 also indicate that while R1 is a fall risk, they did not sustain a fall in the bathroom on 8/21/2021 or on 8/20/2021. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. The Department’s investigation consisted of an inspection of the facility, observation, analysis of resident records, incident report, and interviews conducted and found no evidence to support the allegation: “Resident sustained an injury from a fall while in care”. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted with Bessie Coelho and a copy of the report was provided.