Complaint·June 9, 2022

On 01/24/2022, the facility submitted an unusual incident/injury report to CCL for review. The incident report indicated, on 01/21/2022 at approximately 1700 hours R1 fell in the dining room while transferring chair back to R1’s wheelchair. R1 was transported to Sutter Roseville Medical Center hospital for further evaluation and treatment. R1 was discharged back to the community with no new orders. Interview statement received from staff (S1) indicated, R1 is transferred out of chair usually by standing and grabbing onto table. The wheelchair was not pushed in enough and R1 fell when trying to grab on the table. There was no loss of consciousness or head trauma. The Department had requested for R1’s medical records for review. On 01/22/2022, R1 was discharged from the hospital and was diagnosed with mild to moderate T12 compression fracture. No evident of significant bony canal stenosis. Mild subcutaneous fat stranding seen in the upper left buttock. Osteopenia is noted and degenerative changes are seen throughout the spine. On 01/23/2022, R1 was admitted to Kaiser Permanente Roseville Medical Center due to pain. R1 had X-Rays taken and it was discovered that R1 had a nondisplaced bilateral sacral ala fracture. On 01/25/2022, R1 was discharge from Kaiser. The Department reviewed R1’s physician’s report and level of care assessment. According to R1’s physician’s report, R1 is able to independently transfer to and from bed. According to R1’s level of care assessment which was completed on 02/20/2020 indicates under transfer ability, R1 requires no assistance with transfers. According to Resident Care Coordinator (RCC) Kristina Waldlow, R1 is stand by assist for transfer only. Based on R1’s assessments resident is considered a fall risk and facility took the appropriate measures to provide timely medical attention to R1. This agency has investigated the above listed allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED . An exit interview conducted. On 01/21/2022 at approximately 1700 hours R1 fell in the dining room while transferring chair back to R1’s wheelchair. R1 was transported to hospital for further evaluation and treatment. Interview statement received from R1’s Responsible Party (RP) indicated, R1 was at a Skilled Nursing Facility (SNF) for a short period of time. An evaluation with Kaiser’s liaison and the facility’s Licensed Vocational Nurse (LVN) was conducted which indicated resident can return to the community. It was discovered through interviews that R1’s RP did not receive an eviction notice or any type of notice that R1 cannot return to the community. The Department conducted interviews and gather statement from Resident Care Coordinator (RCC), Kristina Waldlow. According to RCC, there was no contact from SNF discharge of R1. RCC would be the one to refuse residents return due to prohibited conditions, no such refusal occurred. SNFs try to refer to six (6) beds “often”, telling residents and families that they get more individual attention at smaller facilities. R1 will likely be appropriate to return if they and the family choose to. Reappraisal scheduled with SNF for Monday 02/7/2022 and returned participated. This agency has investigated the complaint alleging, unlawful eviction. The Department have found that the complaint was UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without a reasonable basis.