complaint·March 22, 2022

Per the video, S1 was observed pulling on R1’s leg at approximately 5:16 AM. Prior to pulling on R1’s leg, R1 can be seen in video being repositioned and moving freely without any evidence of pain or discomfort. Following the interaction, R1 began to continuously yell in pain. Despite R1’s yelling, S1 can be heard repeatedly instructing R1 to stand up and to stop yelling. As R1 grabbed onto bedding, S1 was observed yanking R1’s hands free in an effort to force her to stand up with the assistance of a walker which resulted in R1 sliding from the side of the bed onto the floor at 5:18 AM. S1 picked up R1 from by the waist and attempted to placed R1 on the bed again. When R1 reached out and placed a hand in front of them on the bed, S1 was observed forcibly shoving R1 from the back, face first onto the side of the bed with R1’s legs hanging over the edge of the bed. At 5:22 AM, S1 was observed grabbing R1 up by the ankles and lifting R1 off the floor and onto the bed. During this time R1’s full body weight can be observed resting on their head and neck. Throughout the incident R1 repeatedly yelled in pain and screamed for help. At no time during the incident did S1 call for assistance with R1. After attempting a second time to force R1 to stand, S1 was joined by R1’s responsible party at 5:25 AM who requested S1 to stop while they called for other caregivers to assist. At 5:34 AM S1 was joined by another caregiver who completed R1’s incontinence care with the help of R1’s responsible party. The facility staff did not call 9-1-1 or consult R1’s primary care physician. R1 was later taken to Orange County Global Medical Center for evaluation by their responsible party on 10/02/2021 where R1 was diagnosed with a right inferior ramus fracture. Although the age of the fracture could not be determined, during R1’s hospitalization for an unwitnessed fall on 9/24/2021, a pelvic x-ray was completed and no mention of any pelvic injury was noted by the treating physician. Per documents reviewed and interviews conducted, it was confirmed R1 was listed as a known fall risk. R1 is listed as having a diagnosis of Dementia and requires full assistance with ADLs. R1 was confirmed to be unable to communicate details of incidents that occurred on 9/24/2021 and 9/30/2021. Interviews with interviewees concluded that although R1 was screaming “Help me, help me” while being assisted by S1. During the investigation, it was concluded that S1 was untruthful while providing answers and only told the truth after becoming emotional when shown photographs from the video captured. S1 was hired by the facility via a temp agency to assist with staffing shortages. S1 was observed not to be associated to facility at the time of incident and no required paperwork, including staff training, was observed on file. S1’s contract with the facility has since been terminated. CONTINUED ON NEXT PAGE... Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “Resident sustained injury due to a fall or improper care” has been met; Therefore, the allegation listed above is deemed to be SUBSTANTIATED. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 An exit interview was conducted with Administrator Heather Myers, and a copy of this report, along with LIC9099-D, Appeal Rights, and the LIC 811, identifying confidential names was left at facility.