Complaint·October 27, 2021

A review of the first Physician Communication Fax (PCF) dated 7/9/21 revealed that R1 was found on the floor with cut to right cheek and was sent to the hospital, the 2nd (PCF) dated 7/10/21, revealed that R1 was sent to the hospital for a swollen left knee and notified there was a fracture to the Patella. LPA observed the Physician report(s) dated 2/2/20 and 2/21/21 which indicates that R1 walks/wanders and able to independently transfer to and from bed. A review of the Transfer of Care Summary dated 7/9/21, revealed that R1 was diagnosed with Closed fracture of fourth cervical vertebra; Face laceration. The Transfer of Care Summary dated 7/10/21, revealed R1 was diagnosed with Displaced comminuted fracture of right patella, initial encounter for closed fracture. LPA observed that during interviews of Staff #1 (S1-S6) and physician report all corroborate that R1 was able to ambulate (walk/wander) without the use of any devices. The investigation revealed that S1 was finishing laundry duties when R1 arrived at the dining area. S1 began walking with R1 to the chair that was familiar to R1. S1 turned to relocate a hamper to ensure it would not become a hazard when S1 heard the chair R1 had was sliding away from the resident. By the time S1 tried to grab the chair, R1 had already fallen to the floor. S1 called for help when S2 arrived who called 911 and S3. Based on interviews, documentation, and medical records, there appears to be no negligence on behalf of the staff. The facility reported the incident timely seeking immediate medical attention, to Responsible party (RP), Primary Care Physician (PCP), and Community Care Licensing (CCL) for R1. LPA observed that the requirement of ensuring that dementia care residents have an annual assessment was completed. LPA did not observe documentation on the 2020 physician report or the 2021 physician report that indicated R1 needed 1:1 care nor did R1 have any motor impairment/paralysis. The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.