complaint·September 12, 2023

LPA interviewed S4 who stated that staff was documenting when F1 was being given and that staff were providing this for the resident. Therefore, based on the above information LPA was unable to corroborate the allegation that staff was not provided with F1. Therefore, the allegation is unsubstantiated . Findings that are unsubstantiated mean that although the allegation may be valid, the preponderance of the evidence standard has not been met. An exit interview was conducted with Executive Director, Maria Arriaga, where this report was reviewed and provided to them. The department interviewed staff who stated they are assigned a “round” described as an assignment of residents for the day. The staff stated there are six (6) “rounds” with a staff assigned to each “round”. Staff #1 (S1) stated that on 09/06/2022 the facility was “short staffed” and only had four (4) caregivers to cover the six (6) rounds. Staff #2 (S2) confirmed that R1 was one of the residents assigned to their “round” on 09/06/2022. Staff interviews revealed conflicting information. S1 reported they asked S2 to assist with R1. S1 reported they “struggled” lifting R1 to a standing position because R1 was “putting up a fight”. S1 reported R1 had been combative, and after changing had been “tugging” on the staff’s arm and as a result R1 tripped over the floor transition strip in the restroom and fell. S1 reported trying to catch R1, but due to the momentum of the fall, S1 fell “on the side” of the resident. S1 provided conflicting information when they were re-interviewed. S1 later stated they had fallen partially on R1’s body but denied placing their full body weight on R1. Staff interview with witness revealed, S2 assisted S1 with changing R1. It was reported S1 had “rushed” the resident, “pushed” the resident with their hand which caused the resident to trip over S1’s leg and fall onto their back. It was further reported, S1 tried to catch R1 but R1 was “too heavy” and S1 ended up falling with their “whole body” on top of R1’s leg, and R1 immediately screamed. A review of facility progress notes dated 9/6/2023 1:46 p.m, revealed a third version of what occurred, which was that S1 reported that R1 had fallen on their right knee, causing the resident to fall and be injured. A review of text messages starting 9/11/2022 from S1 to S2 revealed S1 making several attempts to convince S2 to “be on the same page” and report that R1 was being combative and fell over the floor transition strip. Based on the totality of evidence, from interviews conducted and records review; the allegation resident sustained a fractured femur as a result of staff neglect, is substantiated. An immediate civil penalty of $500 is being assessed in accordance with Health and Safety 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. Regarding allegation, “ Staff did not seek immediate medical treatment for resident.” R1 fell on 09/06/2022. Interviews with staff revealed, R1 screamed immediately after the fall. Staff reported seeing R1 in pain with a swollen knee and leg. This incident was reported to Staff #3 (S3) who assessed R1 and then called hospice. Hospice notes dated 9/6/2022 revealed hospice staff assessed R1. A mobile x-ray unit was requested and came out to the facility on 09/07/2022. The x-ray was completed for R1’s knee, as staff were told, R1 fell on their knees. Radiology report dated 9/7/2022 revealed, the x-ray was negative for an injury to R1’s knee. Staff interviews revealed R1 was still observed to be in pain after the x-ray. R1’s POA, then insisted on R1’s foot and hip being x-rayed. Additionally, Staff #4 (S4) documented on facility progress notes 9/8/2022 R1’s upper right thigh in an “awkward” position. On 09/09/2022, a second X-ray was conducted. Radiology report dated 9/9/2022 revealed, the x-ray showed a right femoral fracture. R1’s doctor requested R1 be sent out for possible surgery. A total of five different staff interviews, revealed, they believed R1 was in pain because R1 appeared “pale” in the face and had swelling and redness on their knee and leg. A review of progress notes, dated between 9/06/2022 and 09/09/2022, corroborated that R1 was changed and transferred to and from their recliner and had been observed to be in pain. Therefore, from the time of the fall on 09/06/2022 to 09/09/2022, three (3) days had elapsed where the resident was observed to be in pain and staff did not seek medical attention. Therefore, the allegation is substantiated. Regarding allegation “Staff do not inform resident's authorized person of incidents”, it was alleged that resident had fallen at the facility several times and that the resident’s POA had not been informed about some of the falls when they occurred. LPA conducted a file review of the facility and found that falls documented on hospice progress notes for 6/3/2022, 3/18/2022, 2/24/2022 and 2/21/2022 had not been reported to the department. LPA also found that fall resulting in a femoral fracture on 9/6/2022 had not been reported until 9/14/2022, past the 7-day reporting requirement. It was also found during department investigation that S1 had not given accurate account of events for R1’s fall on 9/6/2022. It was only found during this investigation and through re-interviewing S1 that S1 had fallen on top of R1. Therefore, based on this information the allegation is substantiated Substantiated findings mean that the preponderance of the evidence standard has been met. Deficiencies were cited for substantiated allegations according to the California Code of Regulations Title 22 Division 6 Chapter 8. Plans of correction were documented and created with Executive Director, Maria Arriaga, along with deficiencies on an LIC9099-D page. An exit interview was conducted with Executive Director, Maria Arriaga, where this report along with civil penalty page LIC421IM, LIC9099-D pages, and appeal rights were reviewed and provided to them.