Inspector’s narrative
What the inspector wrote
***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The purpose of this report is to re-issue citations. The finding remains as Substantiated. ***
On 04/11/24 visit, LPAs Tao and Reyes continued the investigation, interviewed Administrator, staff, and residents, conducted a physical plant with staff#9 (S9), and delivered the complaint investigation findings.
Regarding allegation: Resident sustained a hematoma while in care. It is alleged that a resident fell twice in the facility and was hospitalized for two days after the second fall. Upon return to the facility, a resident was placed in a seat belt for fall prevention; however, staff failed to secure the resident’s seat belt, resulting in a subsequent fall causing serious injury to the resident.
The investigation consisted of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident sustain of hematoma. R1 was not interviewed due to R1’s medical condition. Per staff interviews, seven (7) out of nine (9) staff revealed that staff were aware R1 had fallen in the facility and two (2) of nine (9) staff denied knowledge that R1 fell in the facility. Eight (8) of nine (9) staff reported there was adequate care and supervision provided at the facility. One (1) of nine (9) staff reported staff left R1 alone and R1 sustained a fall. Review of incident report dated 08/24/21, indicated R1 fell in the facility and was taken to the hospital for medical treatment, and discharged to a Rehab for continued care. Review of 09/23/21 incident report, indicated R1 fell in the facility a second time and was sent to the hospital for medical treatment. The facility notified the department of R1 falls in a timely manner. On 08/24/21 around 11PM, R1 fell in the facility and was transferred to the hospital on 08/24/21 for medical treatment, R1 was discharge from the hospital on 08/25/21 and returned to the facility; however, R1 complained of pain and was sent back to the hospital on 08/25/21. R1 sustained a right shoulder fracture and subdural hematoma. On 08/31/21, R1 was transferred to a different hospital for rehabilitation. On 09/15/21, R1 returned to the facility. On 09/23/21, R1 sustained a subsequent fall in the facility while sitting in R1 wheelchair. R1 was transported to the hospital on 09/23/21 for medical treatment. R1 hospital records, dated 09/23/21, indicated R1 sustained an acute chronic bilateral subdural hematoma.
(-continued in LIC 9099C-)
***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The purpose of this report is to re-issue citations. The finding remains as Substantiated. ***
Therefore, the investigation revealed the facility did not conduct a reappraisal of R1’s fall risk after R1 fell in the facility on 08/24/21; the facility did not update R1’s care plan for fall prevention; R1 sustained a fall on 08/24/21 resulting in injury and sustained a subsequent fall on 09/23/21, which resulted in R1 sustaining injury/aggravation to R1’s previous injuries.
Regarding allegation: Staff did not provide adequate supervision. It is alleged that a resident fell three times in the facility. Resident was hospitalized after the second fall for two days and returned to the facility; however, due to staff not providing adequate supervision, the resident sustained a third fall.
The investigation consisted of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident fall at the facility and residents stated staff treated them fine. R1 was not interviewed due to R1’s medical condition. As mentioned above, per staff interviews, seven (7) out of nine (9) staff revealed that staff were aware R1 had fallen in the facility and two (2) of nine (9) staff denied knowledge that R1 fell in the facility. Eight (8) of nine (9) staff reported there was adequate care and supervision provided at the facility. One (1) of nine (9) staff reported staff left R1 alone and R1 sustained a fall. Review of incident report dated 08/24/21, indicated R1 fell in the facility and was taken to the hospital for medical treatment, and discharged to a Rehab for continued care. Review of 09/23/21 incident report indicated R1 fell in the facility a second time and was sent to the hospital for medical treatment. The facility notified the department of R1 falls in a timely manner.
The investigation revealed, on 08/24/21 around 11PM, R1 fell in the facility and was transferred to the hospital on 08/24/21 for medical treatment, R1 was discharge from the hospital on 08/25/21 and returned to the facility; however, R1 complained of pain and was sent back to the hospital on 08/25/21. R1 sustained a right shoulder fracture and subdural hematoma. On 08/31/21, R1 was transferred to different hospital for rehabilitation. On 09/15/21, R1 returned to the facility. On 09/23/21, R1 sustained a subsequent fall in the facility while sitting in R1 wheelchair. R1 was transported to the hospital on 09/23/21 for medical treatment, R1 hospital records dated 09/23/21, indicate, R1 sustained an acute chronic bilateral subdural hematoma.
(-continued in LIC 9099C-)
***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The purpose of this report is to re-issue citations. The finding remains as Substantiated. ***
Therefore, the investigation revealed the facility did not provide adequate care and supervision to R1, resulting in R1 sustaining multiple falls on 08/24/21 and 09/23/21, both falls resulted in R1 sustaining injury. Additionally, the facility failed to conduct a reappraisal to R1’s fall risk after R1 fell in the facility on 08/24/21 and did not update R1 care plan for fall prevention.
Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is 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 $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining serious injuries.
The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).
Exit interview conducted with Amber, Licensee. Appeal Rights were discussed, and a copy of Licensing Report and Appeal Rights were given during visit.
***This report serves as an amendment and supersedes the original complaint investigation report created on 04/11/24. The finding remains as unsubstantiated. ***
On 04/11/24 visit, LPA Tao and Reyes continued the investigation, interviewed Administrator, staff, and residents, conducted a physical plant with staff#9 (S9), and delivered the complaint investigation findings. The investigation consisted of the following.
Regarding allegation: Resident was restrained. It was alleged that resident was tied into a wheelchair. The investigation revealed of the following. Per resident interviews, seven (7) out of seven (7) residents could not corroborate the allegation and revealed they were not aware of any resident being tied to residents’ wheelchairs. R1 was not interviewed due to R1’s medical condition. Per staff interviews, all staff denied the allegation and revealed staff did not tie residents to their wheelchairs. Review record revealed the facility did not allow restraining residents in any form. Per LPAs’ observation, no residents were being tied to the wheelchairs when conducting the physical plant. Therefore, there’s not sufficient evidence showed resident was restrained at the facility.
Regarding allegation: Licensee has been suspended by the franchise tax board. It was alleged that the franchise tax board suspended the Licensee. The investigation revealed of the following. Per record review, the Franchise Tax Board had received and confirmed the licensee had filed tax to the board for the last two years and current year. Therefore, the franchise tax board did not suspend the licensee.
Although the allegation may have happened or is valid, there’s 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 Amber, Licensee. A copy of Licensing Report was given during the visit.
