complaint·August 19, 2025

The change of face technique is a non-confrontational behavior intervention used when a resident becomes agitated during an interaction with a particular staff. The approach involves substituting the current staff with a different staff member, often leading to a reset in the residents emotional state. Through interviews, it was alleged that while showering R1, R1 took a step backwards, lost their balance, fell, and struck their head on the wall. The facility staff attempted to catch R1 prior to the fall but their attempt was unsuccessful. The facility’s protocol does not allow staff to move the residents after an injury as it may harm the residents. The ambulance was immediately called, however, a valid signed, Do Not Resuscitate (DNR) was located in R1’s file. Through observations, the facility’s bathrooms complied with Title 22, regulation 87303, as s howers were equipped with non-skid mats and grab bars. In addition, information obtained through interviews revealed that the facility’s protocol after any client falls, the service plan will be updated based on any specific need. This is to prevent any further falls and address safety measures. Residents will also participate in a re-evaluation provided by a medical professional after so many fall incidents. No reassessment was completed due to R1 passing. Furthermore, the facility complied with all protocols pertaining to R1’s needs and service plan, such as conducting checks on R1 and assisting R1 with their medications. Staffs training records were current, Staff implemented de-escalation techniques pertaining to R1’s agitated state at the time of the incident. According to the autopsy received by the Coroner’s Office, the reported cause of death was accidental and due to blunt force trauma. Based on observations, interviews and records reviewed, the allegation of staff was negligent in resident's death is unsubstantiated. A finding that is unsubstantiated means although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where a copy of this report was reviewed and provided to Assistant Director, Anna Martinez.