complaint·February 15, 2024

Based on the interview, four out of the four staff indicated that R1 was provided and encouraged to use a walker however refused to use it, and the family member corroborated with this statement. Facility record shows R1 sustained injuries from two falls on October 17, 2022 and November 2, 2023. In between the one-year time frame, Staff #1 (S1) and the family member indicated that R1 had few minor slips from the chair or bed, however injuries were not sustained. The four other interviewed staff did not observe other falls. On October 17, 2022, R1 suffered a mechanical ground-level fall in the facility bathroom and sustained a fractured elbow and was subsequently placed on a cast as per the UCI Health medical report dated November 14, 2023. R1’s cognitive functions began to decline, and the Physician’s Report was updated to reflect R1’s change of condition on October 23, 2023. On November 2, 2023, approximately 9:00am, R1 suffered a mechanical fall in the living room and sustained closed fracture of multiple ribs of right side, facial injury, and a laceration of forehead per the UCI Health medical report dated November 14, 2023. Staff #2 (S2) present at the time of the incident indicated that R1 was using a walker. Four staff and one resident interviewed also confirmed that S2 was present during the fall. Based on the Department’s investigation, due to R1 being considered ambulatory from their most recent assessment dated October 23, 2023, and had not suffered from a fall or an injury for over one year, the evidence obtained did not support the allegation. In addition, the facility staff provided supervision and had taken appropriate measures to seek medical attention in a timely manner. Therefore, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Frances Umali, and a copy of this report including the LIC9099C, and the LIC811s were provided at the end of the visit.