complaint·September 19, 2023

Continued LIC9099-C page 2 Allegation #1: Resident sustained a fracture while in care. Staff members 1-6 (S1-S6) stated resident sustained a fracture while in care from a fall. The facility had no control over the fall and could not have prevented the resident from falling. The resident was in his bedroom in his recliner chair after breakfast and had an unwitnessed unforeseen fall. The facility staff immediately went to the resident's bedroom to check on the resident and provided assistance. The hospice nurse called 911 immediately and paramedics transported the resident to the hospital where he was diagnosed with a left femur fracture. S1-S6 stated that the facility staff are well-trained, adhere to Title 22 Regulations, and took all necessary precautions. Allegation #2: Facility failed to meet report requirements Staff 1-6 (S1-S6) members interviewed stated a written special incident report (SIR) was reported and submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. Staff 1-2 (S1-S2) stated this report includes the resident's name, age, sex, date of admission; date and nature of the event; attending physician's name, findings, and treatment, and disposition of the case. S1-S2 stated a follow-up SIR was also reported regarding the death of the resident, the cause of death, and where the death occurred. S1-S2 stated that the incident did not occur because of neglect and lack of supervision. S1-S6 stated staff could not have prevented the fall from happening. S1-S6 denied the allegation. Allegation #3: The facility did not notify the resident's POA of an incident Staff 1-6 (S1-S6) stated that the facility gave the resident’s information to the paramedics and Long Beach Memorial Hospital. The hospice nurse and Administrator came to the facility immediately after the resident had fallen. The Hospice nurse and the Administrator informed the resident POA of the incident. The staff is not aware of how long it took the POA to locate the resident. The Administrator stated they give the paramedics the resident, physician reports, medications, and contact information. The Administrator stated they reported the Special Incident Report and informed Community Care Licensing and all the appropriate agencies in a timely manner. See continued LIC9099-C page 3 Continued 9099-C page 3 Allegation #4: Failed to meet resident's needs Staff 1-6 (S1-S6) stated the facility staff did not fail to meet the resident's needs. S1-S6 stated staff went to the resident's bedroom and immediately provided assistance to make sure the resident was okay. S1-S6 stated the facility staff are providing residents with care and supervision as necessary to meet the resident's needs. S1-S6 stated they assist residents with their daily needs. Investigation revealed the following: Staff 1-6 (S1-S6), stated that on 01/29/2023, not sure of the exact time. The resident was in his bedroom sitting in his recliner chair after breakfast and had an unwitnessed unforeseen fall. The facility staff immediately checked on the resident. The resident reported pain in his left hip area. Staff contacted the administrator, the hospice nurse, and 911. The resident was transported by paramedics to Long Beach Memorial Hospital where he was diagnosed with a left femur. The resident had surgery which was successful, however, the resident did not regain consciousness after the procedure. The resident was placed on palliative care and passed away at the hospital.  S1-S6 and residents 2-5 (R2-R5) interviewed denied the allegations. S1-S6 stated that the incident did not occur because of neglect or lack of care and supervision. S1-S6 stated staff couldn't have prevented the resident from falling. It was not the staff’s fault and it was an accident. S1-S6 stated that the facility staff are well-trained and competent, adhere to Title 22 Regulations, and took all necessary precautions. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to Administrator. There were no deficiencies cited. Exit interview conducted.