complaint·March 2, 2024

Assessment (dated 06/25/20), Hospice Care Plan (effective 07/08/21), Hospice Notes (dated 07/09/21), Medication Administration Records (June 2021 thru July 6, 2021), Administrator's Certificate, Facility Sketch, Facility Sign-in/Sign-out sheets (June 2021 thru July 6, 2021), Daily Routine Schedule (June 2021 thru July 6, 2021), House Rules, Facility Staff In-service Training (dated 04/30/21, 07/08/21, 07/09/21, 07/12/21, 07/13/21, 07/14/21, 07/15/21, 07/28/21), Incident Reports (dated 01/19/21, 01/29/21, 03/13/21, 05/31/21, 06/09/21, 06/19/21, 06/27/21), facility staff work schedules (June 25, 2021 thru June 30, 2021), facility staff and residents’ rosters. This complaint investigation was referred to California Department of Social Services (CDSS), Investigation Bureau (IB) and assigned to Investigator Robert Kujawa. The investigation included interviews with medical services staff (Witness #1), family members (RP/POA), facility staff (A1, S1 – S5), and residents (R1 – R5) and a review of medical records (dated 07/01/21 – 07/08/21) from St. Mary Medical Center Long Beach. INVESTIGATION REVEALED THE FOLLOWING: Regarding Allegation #1 : Resident #1 sustained multiple falls at the facility based on a review of facility incident reports (dated 01/19/21, 01/29/21, 03/13/21, 05/31/21, 06/09/21, 06/19/21, 06/27/21). Resident #1’s last known fall was on 06/27/21, the resident sustained an injury for which the resident did not receive medical treatment until four (4) days later 07/01/21. Facility staff notified the resident’s physician and family members about the fall; and Resident #1 showed no signs of injury or complaint of pain and discomfort at the time of the fall on 06/27/21. Resident #1 began complaining of pain in their right arm on 07/01/21; and facility staff notified the resident’s physician who examined Resident #1 who requested that the resident be transported to the hospital’s ER. Resident #1 was transported and admitted to St. Mary’s Hospital on 07/01/21. Upon discharge from the hospital on 07/08/21, Resident #1 returned to the facility with a sling on their right arm after undergoing treatment. Interviews conducted of medical services staff and a review of hospital medical records (dated 07/01/21 – 07/08/21) documented Resident #1 sustained a closed fracture of neck of right proximal humerus diagnosis during their last known fall on 06/27/21. Interviews conducted of facility staff corroborated that Resident #1 had sustained multiple falls and received the proper care from facility staff following each fall. Facility staff took steps according to the resident’s fall-risk plan to try and prevent further falls by vocalizing resident to ask for assistance. (Evaluation Report continues LIC 9099-C) Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Neglect/lack of care and supervision resulted in the resident falling multiple times and sustaining an injury while in care is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation(s) issued (ref. LIC 9099D). Civil penalty assessed. Regarding Allegation #2 : this investigation revealed that facility staff did not seek medical care to Resident #1 until four (4) days after the resident’s last known fall on 06/27/21 because the resident complained of pain to the right arm on 07/01/21. Resident #1 was transported to St. Mary’s Hospital Emergency Room (ER) for further evaluation and was admitted to the hospital with a diagnosis of right proximal humeral meris fracture. Resident #1 was evaluated by an orthopedic specialist recommending non-surgical intervention, as it would heal itself. Interviews conducted of facility staff corroborated that after each unforeseen fall, Resident #1 was evaluated for pain by facility staff - along with notifications made to the resident’s physician and family members based on documented incident reports (dated 01/19/21, 01/29/21, 03/13/21, 05/31/21, 06/09/21, 06/19/21, and 06/27/21). A review of the resident’s medical records documented that Resident #1 had a history of falls and was at a high-risk for falls. Resident #1’s physician recommended to facility staff: a plan of action - which facility staff updated and implemented on the resident’s appraisal/needs and services plan and fall-risk plan. Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff did not seek timely medical treatment for resident is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation(s) issued (ref. LIC 9099D). An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Wellness Director (Fabiola Marciano). ECP: 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 any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”