complaint·February 5, 2025

(Continued from Page 1) Medical records were obtained. The review of the Consultation dated 11/12/2022 revealed the chief complaint of R1 using the walker as a wheelchair and fell, with complaint of pain in the occipital region and lumbar area. The Assessment/Plan section of the consultation revealed “Right-sided L1-3 transverse process fractures following a fall out of the wheelchair.” Staff interviews were conducted. The staff reported the ED was doing transportation on the day of the fall. R1 was taken to a medical appointment. The staff revealed speaking to the ED after the incident. The staff reported the ED informed them when the ED arrived to pick up R1, R1 refused to walk and demanded to be pushed on the walker. The wheel of the walker hit the concrete, the walker tilted and R1 fell onto the concrete. When R1 complained of pain, the ED called 911. The staff further revealed that the walkers are not meant to be sat on and that this is common knowledge at the facility. A second staff interviewed, revealed R1 could walk with a walker, and it had a seat in the middle. This second staff also stated residents and staff were not allowed to use the walker as a wheelchair. ED admitted that R1 was pushed on their walker and due to the walker hitting an obstruction on the floor, R1 fell off walker and onto the floor. The ED reported R1 sat down on the walker, facing him, and he started to push R1 on the walker. The walker hit something that he assumed was the union between two tiles and R1 fell backwards onto the floor. R1 complained of pain and the ED called 911. The ED described the walker as having a seat in the middle with a back rest. When asked if this was a dual function walker that could also be used as a wheelchair, the ED replied he did not like to use it as a wheelchair. The ED reported he discouraged other residents from using it as a wheelchair. However, he denied ever telling caregivers to monitor or remind residents to not use the walker for that purpose. The ED also denied knowing about any policies that talked about the proper use of the walker. The ED reported that he was now aware that the walkers were not safe to be used as wheelchairs. Based on review of a website called unicarehealth.com the seat walker cannot be used as a wheelchair. The product is designed to give the resident a rest as they fatigue or become unsteady. The website goes on to explain the structure of the frame and wheels provide only a small wheel base which can tip easily if the walker hits a curb or bump in an uneven pavement or path. When the resident is in a seated position and being pushed backwards, the seat has little support for the resident in this instance causing them to fall in a backwards direction with little or no opportunity to facilitate any action to save themselves from the fall. (Continued on Page 3) (Continued from Page 2) Based on interviews, record reviews and review of website for proper use of a similar product, the allegation that due to staff neglect, staff caused injuries to resident while in care is Substantiated. This poses a health and safety/personal risk to residents in care and the facility will be cited on Title 22 Regulations. An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted where this report, 9099D, and LIC421 along with appeal information was discussed and provided.