complaint·October 12, 2023

The investigation revealed the following: Regarding allegations resident sustained a fracture due to staff neglect and staff did not seek medical attention for resident. It is alleged R1 sustained a fracture to the left tibia on 4/29/23 and facility did not call 911. Interviews conducted with administrator and staff revealed the following: On 4/29/23 Staff #1 (S1) assisted R1 with a shower and strapped R1 to the chair to prevent slipping. S1 wheeled R1 in the chair to R1’s bed. S1 stepped outside the room to ask Staff #2 (S2) for assistance transferring R1 to the bed but, S2 was busy at the time. S1 said they returned to the room, “became inpatient” and lifted R1 from the chair, who was still strapped to the chair. R1 was pulled back and fell down along with the chair and S1. Administrator was made aware of the fall. Family representative was contacted by administrator and informed of the fall. Per administrator they monitor R1 between 4/29/23 to 5/1/23 and did not observe bruising, swelling, or indication of pain. On 5/2/23, administrator observed swelling on R1’s left leg. An in-house x-ray was conducted, and results were texted to administrator at around 11:00pm which noted a fracture was found. X-ray Result dated 5/2/23 at 10:47pm notes: Acute fractures of the proximal tibia and fibula. On 5/3/23, R1 was sent to the hospital at around 6:00am. On 6/19/23, administrator stated S1 was aware that a two-person assist was required to transfer R1. As a result, the administrator verbally reprimanded S1. On 5/24/23, investigator attempted to interview R1 and was not able due to cognitive skills. On 5/24/23, interview conducted with S2 revealed, S2 was aware that R1 needed a two-person assist but became inpatient and decided to lift R1 alone. Physician’s report dated 4/29/21 notes R1 is motor impaired and requires continuous bed care. R1 has limited ability to communicate needs and needs assistance with most ADLs (assistance of daily living). Based on LPAs observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustained a subdural hematoma while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(f); if the department determines the death of the client is due to neglect. Exit interview was conducted with Linda Fan and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff left resident in a soiled diaper for an extended period of time. It is alleged R1 would smell like urine because R1 wasn’t being changed. Interviews conducted on 10/12/23 revealed the following: Interviews conducted with 3 out of 3 residents revealed residents are check often, at least every two hours. Residents do not smell due to the lack of incontinence care. Interviews conducted with 3 out of 3 staff revealed residents that required assistance with incontinence are check every two hours and change as needed. One resident is changed regardless the resident is soil or not every two hours, per family request. Interviews conducted with 2 family representatives revealed facility assist with incontinence care and residents are always clean and free of odors when visiting. Facility keeps a monthly incontinence care log for the residents, staff notes initials and reason for changing upon assisting the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Linda Fan and a copy of this report was provided.