complaint·January 24, 2024

CONTINUED FROM LIC9099 - Multiple signed testimonies by staff members were additionally provided by facility during the visit in addition to Medication Administration Records for resident R1. Physician follow-up notes for visits from R1's primary care providers dated February 8, 15, 18 and 22nd, 2022 also provided. On February 17, 2022, R1 was transferred to Placentia Linda Hospital via after paramedics were activated due with complaints of a low grade fever, low oxygen saturation and emesis. R1 was evaluated at the hospital and received lab and imagery testing before being discharged to the community on the same day. Upon arrival at the hospital, R1 was observed to have some bruising present in the hip region that prompted hospital staff to conduct x-ray in order to rule out further injury. No fractures were assessed to be present per R1's discharge notes. Regarding the allegation that Resident sustained unexplained injuries while in care , the following has been concluded: Based on a review of hospital records as well as staff interviews and seven separate written and signed statements provided during the investigation, no bruising had been observed by facility staff during toileting care provided prior to the activation of paramedics, suggesting that the bruising may have occurred during the ambulance transport. Furthermore, no additional injuries were assessed at Placentia Linda Hospital where the ultimate diagnosis documented was of a Urinary Tract Infection. Regarding the allegation that Facility did not seek timely medical attention for resident, the following has been concluded: Based on resident records, facility charting and hospital records, there is little to no evidence of a delay in providing necessary medical attention to R1. Routine appointments with the resident's primary care provider had taken place weekly prior to the hospitalization and the resident was additionally followed upon twice after their discharge. Regarding the allegation that Resident sustained pressure injury while in care, the following has been concluded: Resident had a physician order for Calmoseptine dated February 2, 2022 for the treatment of a rash in the resident's diaper area for a period of 10 days. The physical examination performed at Placentia Linda Hospital on February 17, 2023 indicates the skin condition to be "Normal color, no rash". Facility charting additionally does not evidence the presence of pressure injuries at that time. The three allegations above are therefore found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM LIC9099-A Multiple signed testimonies by staff members were additionally provided by facility during the visit in addition to Medication Administration Records for resident R1. Physician follow-up notes for visits from R1's primary care providers dated February 8, February 15, February 18 and February 22, 2022 were also provided and copied. Regarding the allegation that Staff did not notify responsible party of incident, the following has been concluded: Copies of electronic messages sent to the resident's responsible party and attorney-in-fact on February 17, 2022 were provided during the investigation, confirming that they were promptly notified of the change in condition and of the decision to make a call the paramedics for evaluation resulting in the transfer to Placentia Linda Hospital on the same day. As a result, the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative.