complaint·April 10, 2023

wheelchair regular chair. A review of documentation revealed that on or around December 27, 2021 R1 had sustained a fall and was noted to be leaning on their right side with increased weakness. A facility file review revealed that the facility did submit an unusual/special injury report to the regional office on December 28, 2021 for being sent out due to elevated blood pressure, however the diagnoses given at the emergency room was a broken hip, requiring surgery and rehabilitation. Therefore, the allegation of facility did not notify resident's family of resident's fall(s) Is SUBSTANTIATED. Staff did not report resident's fall(s) to the facility. R1 was noted to have a motor impairment as they have weakness and neuropathy. As a result, R1 used a wheelchair, walker and required a two person assist. A review of documentation revealed that on October 11, 2021 R1 did sustain a fall that was noted to not have been reported, by the previous administrator Queen Ayers. Queen was not aware of the incident until having to follow up being asked about a fall, amongst other reported concerns. Queen reported that there was a fall that did occur on October 11, 2021 during the NOC shift and that R1’s family was not notified. Based on record review the allegation of staff did not report resident's fall(s) to the facility is SUBSTANTIATED. Staff threatened resident It was reported that sometime in October 2021 that staff #1 (S1) would only assist R1 with getting dressed if they got up at 4:00am. In addition, S1 forces R1 to sit on the lid of the commode that is described as being hard. Further reports stated that if R1 was complaint to S1 then they will be left to sit not dressed until their next shift. It was also reported that R1 stated that S1 was mean to them and that they were afraid to speak up, as doing so would make matters worse out of retaliation. Additionally, an internal investigation was conducted and S1 was not to provide any care unless it was an emergency until they could be retrained. Based on observation and record review the allegation is SUBSTANTIATED. A SUBSTANTIATED finding means that the preponderance of evidence standard has been met. Therefore the allegation is substantiated. An exit interview was conducted, and a copy of this report, 9099d, appeal rights, and LIC 811 were reviewed and provided to Executive Director Cindy Garcia. Facility did not seek resident timely medical attention for a broken hip. Regarding the facility did not seek resident timely medical attention for a broken hip. A review of documentation revealed that on or around December 27, 2021 R1 had sustained a fall and was noted to be leaning on their right side with increased weakness. Further documentation reviewed revealed that R1 was not complaining of any pain or discomfort. In addition, a review of documentation revealed that on December 28, 2021 R1 was noted to have elevated blood pressure. A further review revealed that prior to being noted to have elevated blood pressure, R1 was noted to have had slid off of their bed and did not have any injuries. R1 was sent out for a medical evaluation after staff observing that R1's blood pressure was elevated. Based on record review the allegation of facility did not seek resident timely medical attention for a broken hip is UNSUBSTANTIATED. Staff handled resident in a rough manner Regarding the allegation of staff handled resident in a rough manner. A review of documentation revealed that when staff helps R1 up that they pull them by their arm, and that other staff helps R1 by giving a little push on their back. Interviews conducted revealed that R1 would fall back, sticking their arms and legs out when being transferred, making it difficult at times. Including when being transferred from their wheelchair R1 preferred to have the leg extenders out. Staff reported to have to give constant reminders as having the leg extenders out could result in an injury. A further review of documentation revealed that when an internal investigation was conducted and that R1 refused to use the gait belt and wanted to be pulled up by their arms when being transferred. Further information notes that R1 felt that they were being pushed when staff placed their hands on their back, but other feedback notes that R1 preferred to have a hnd on their back.. Due to the conflicting information the allegation of staff handled resident in a rough manner is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report, 9099d and LIC 811 were reviewed and provided to Executive Director Cindy Garcia.