complaint·February 11, 2025

More specifically, diagnosis was acute displaced right distal femur fracture. Per interviews, facility staff denied there was a fall or other known trauma to explain the injury. According to physician doctor who treated R1 while at the hospital, R1’s age and medical condition made R1 more susceptible to the fractures. However, physician reported that some type of force or trauma was still necessary to cause the fracture. Though the exact mechanism of the injury cannot be established, a fall, drop or some other trauma during a transfer cannot be ruled out. According to the Osteoporosis Foundation website, fragility fractures result from low level or low energy trauma, such as a fall from standing height or less. According to facility records, R1 was non-ambulatory, and wheelchair bound. R1 was confused, disoriented, and not able to indicate how injury occurred. In addition, Records revealed that R1 needed help with transferring from the bed to the wheelchair. R1 also needed assistance with bathing, showering, toileting, grooming, dressing, and feeding. R1 further needed assistance with medication management and administration. It was specifically indicated that R1 could not bear weight, kept legs in curled up position, and was resistant to straightening legs. Based upon further review of R1 records, services such as care, supervision, and observation for changes in physical, mental, emotional, and social functioning was to be provided. However, the preponderance of evidence supports that facility staff failed to implement a care plan to address R1 needs. As a result, on or around August 30, 2023, while at the facility, R1 sustained an unexplained fracture. The above allegation is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Facility Manager Eldalin De Deugd.