complaint·August 3, 2023

On R1’s physician report dated March 8, 2022, R1 was diagnosed with mild cognitive impairment. A fall risk assessment evaluation was conducted on April 5, 2022, and it was noted that R1 is a fall risk, and the three falls that were sustained in the span of twelve months, resulted in a hospitalization and with a fracture. On December 17, 2022, staff (S2) went to R1’s room and found R1 on the floor with a laceration on the head, was disoriented, and had dried blood covering their head. Per interview with the S2 upon finding R1 on the floor, it was observed that R1 also had two blood-soaked towels around their head and that R1 reported of having pain in the back of their head. The R1 reportedly had crawled to get towels. It was reported that R1 had “been there for a while as the blood on the towels was as hard as a rock”. On December 17, 2022, 911 was contacted to seek medical attention for R1. R1 was then admitted and evaluated at the hospital, and per hospital staff, R1 sustained injuries, was dehydrated, was soaked in urine, covered in blood and had feces all over. Hospital staff reported that through conversing with S2, S2 expressed being “terrified” because only two caregivers were on duty the night R1 was found. Due to R1 being left unattended from December 15, 2022 to December 17, 2022, the medical attention and care was delayed for R1 who sustained serious injuries: blunt head trauma, concussion, occipital scalp laceration, blunt chest and abdominal trauma and decubitus ulcers to her sacrum. It was alleged that resident was left unattended for an extended period of time . The investigation revealed that on December 15, 2022, R1 fell and called for help, however, did not receive any assistance from staff. R1’s friend called R1 via phone on December 16, 2022, and twice on December 17, 2022, and did not receive an answer, therefore contacted the facility and requested for a staff member to check on R1. On the evening of December 17, 2022, a staff member finally went into R1’s room based on the concerns that R1’s friend had expressed, and staff on duty discovered R1 laying on the floor and observed injuries and dried blood. There were no facility notes that indicated that staff did resident checks from December 15, 2022 to December 17, 2022. Interviewed staff were unaware of their own facility policy called a safety check policy which required caregivers to check in on their residents at least once at night between the hours of 10:00 p.m. and 6:00 a.m. If staff had checked on the R1, the R1 would not have spent two nights lying on the floor in their room in pain with injuries which required medical attention. Based on the information gathered during the investigation and review of documents obtained the preponderance of evidence standard has been met, therefore the allegations are determined to be SUBSTANTIATED. The following is being cited and the Immediate Civil Penalty has been assessed and issued per California Code of Regulations, Title 22 Division 6 Chapter 8, per H&S Code Section 1569.49(f). An exit interview was conducted with ED Howell. A copy of this report was explained, and appeal rights were provided during the visit.