Incident investigation·June 29, 2023

Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an unannounced case management visit to follow-up on an incident report received by Community Care Licensing on 6/21/2023. LPAs met with Executive Director (ED) Rosa Ayala and explained the reason for the visit. Incident report dated 6/21/2023 indicated that on 6/13/2023 at about 3:00 a.m., Staff 1 (S1) and Staff 2 (S2) reported to Staff 3 (S3) that Resident 1 (R1) had redness to their back side. S3 assessed resident, they was able to move extremities with pain, and reported a 3 on a 1-10 pain scale. Resident stated he fell but could not recall details or timing. Primary Care Physician (PCP) was contacted via email and community was advised to monitor. During interviews, ED stated that on 6/13/23, R1 had one episode of vomiting and that was also reported to PCP. A record review of emails dated same date, confirm PCP was notified and inquired whether R1 was able to take a deep breath without severe pain. Staff 4 (S4) confirmed via email that R1 was able to take a deep breath without severe pain and was also “able to walk to lunch just fine” and ate breakfast and lunch with “no more episodes of throwing up.” Per ED, R1’s Responsible Party (RP) was contacted by phone, and a general voicemail was left. RP did not return facility’s call and facility staff did not make an additional attempt to contact RP. On 6/17/23, R1 was picked up for an outing with family. During outing discoloration was observed to R1’s lower back on right hand side. Family took R1 to urgent care and it was determined R1 had sustained rib fractures. During today’s visit, LPAs were unable to interview R1. R1 has not returned to facility following urgent care visit. LPAs interviewed four residents and four out of four were unable to recall observing or hearing R1 fall, and stated they had no concerns regarding falls or staff. Residents are able to call for help with a pendant or pull cord in their bedroom, should they need assistance. Per residents, staff is responsive to their needs. (Cont. LIC809-C) LPAs reviewed and obtained pertinent documentation such as R1’s Physician Report (LIC 602) dated 6/06/23, progress notes for R1 dated 6/6-18/23, email correspondence between facility staff and PCP on 6/13/23, and a picture of R1’s injury taken on 6/13/23. LPA Gutierrez also obtained contact information for S1, S2, S3, and S4 who were not currently present at the facility to be interviewed. LPAs informed ED that subsequent visits and document requests could be required regarding the incident and ED stated they understood. An exit interview was conducted, and a copy of this report was left at the facility.