Inspector’s narrative
What the inspector wrote
Regarding the allegation that staff was rough with resident resulting in injury: it was alleged that Resident #1 (R1), a memory care resident, was handled roughly by staff resulting in bruises. LPA interviewed the facility’s wellness director who stated that R1 was a new resident and on July 22, 2021, S1 witnessed S2 trying to change R1, R1 kept refusing, and S2 forcefully grabbed R1 and changed them, but S1 did not report this incident and it was only discovered the next morning at which point a full investigation was conducted resulting in S1 and S2 being terminated.
LPA reviewed an incident report dated July 27, 2021, which states that on July 22, 2021, at approximately 9:20PM, R1 was changed in a manner which caused bruising to their right forearm, R1 reported this incident on July 23, 2021, S1 and S2 were suspended pending investigation, and local law enforcement, the Long Term Care Ombudsman, and R1’s family were notified of the incident on July 26, 2021. The facility’s wellness director stated that there had been no prior incidents with S1 or S2 and after the incident was discovered, all other residents were checked and no similar injuries were discovered. Per the facility’s wellness director, the facility’s protocol for care refusal is to make multiple attempts, to notify management so other staff can make attempts, and if that does not work to reach out to the family and doctor to explore other options. The facility’s wellness director did not know why this protocol was not followed in this incident, but S2 may have been under pressure to change R1 before the shift ended as later shifts will sometimes complain to prior shifts if something is not done because later shifts will have to do it. Per the facility’s investigation, both S1 and S2 made multiple attempts to change R1, R1 refused both of them, it was S2 who insisted on changing R1 before end of shift, and S1 and S2 ultimately changed R1 together. LPA interviewed R1 who was confused as to why staff were trying to change their clothes, stated they were distraught during the incident, but that they are now doing fine. LPA interviewed three additional residents who reported that they have not experienced staff being rough. LPA confirmed that both S1 and S2 were background cleared. LPA reviewed S1’s staff file which shows that S1 was trained in mandated reporting requirements, had completed their training, and was terminated on July 31, 2021, for violating the facility’s mandated reporting policy when they did not report S2 being rough with R1. LPA reviewed S2’s staff file which shows that S2 was trained in mandated reporting requirements, had completed their training, and was terminated on July 31, 2021, for roughly handling R1. While the facility responded properly after the incident took place, the facility did not take proper measures to prevent incidents like this through sufficient staff oversight, especially in light of knowing that different shifts were pressuring each other to complete tasks prior to the end of their shift, which in this case resulted in forced care.
Regarding the allegation of failure to report: it was alleged that the incident with R1 being handled roughly by staff resulting in bruises was not properly reported to R1’s responsible party. The incident report dated July 27, 2021, timely received in the Orange County Regional Office (OCRO), states that local law enforcement, the Long Term Care Ombudsman, the OCRO, and R1’s responsible party were notified of the incident on July 26, 2021, the same day the facility’s investigation into the incident was completed. However, while the incident report indicates that local law enforcement, the Long Term Care Ombudsman, and the OCRO were notified in writing, it does not indicate R1’s responsible party was notified in writing as required. The facility’s report of suspected dependent adult/elder abuse dated July 26, 2021, similarly, does not indicate that R1’s responsible party was notified in writing. While statements from R1’s responsible party, and the facility’s documentation, confirm that R1’s responsible party was told of the incident as of July 26, 2021, all of the information obtained indicates that this notification was only verbal, and not written, as required. Per staff interview, the facility’s policy is to provide only verbal reports to responsible parties and document the notification.
During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
