complaint·August 17, 2023

Continued from LIC 9099.... The Doctor of Medicine (M.D. ) who reviewed R1’s computed tomography (CT) scan indicated that he could not definitively say when the injuries occurred or if they were a result of the same or different incidents. The M.D. stated that the fractures could have been a month to multiple months old and that they could have occurred at the same time or at different times. The M.D. stated that the cause of the fractures could have been falls, accidents, or direct blows. R1 moved into the facility in September of 2022. Staff reported that R1 was a fall risk and that he fell frequently. Records from the facility document that R1 fell on 11/19/2022, 11/29/2022, 12/16/2023, 12/24/2023, and 02/23/2023. Paramedics assessed R1 after the fall on 12/16/2023, but R1 was not taken to the hospital. Consumnes Fire Department Report #F202220234263 documents that facility staff (S1) signed the Patient Care Report and acknowledged refusal of transport. R1 was not assessed at the hospital until after the fall on 02/23/2023. According to facility staff and records, R1’s c are plan was never updated after he suffered any of his falls. Facility staff indicated that R1 was a fall risk beginning on the date of his admission. Fall prevention measures included reminding R1 to use his wheelchair or walker as well as providing extra visual supervision of him. Facility staff did not implement any other preventative actions to ensure that R1 did not suffer further falls. Based on records reviewed and interviews conducted the allegation of Staff neglect resulted in a resident sustaining multiple injuries while in care is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. As a result of this investigation, deficiencies are being cited from the California Code of Regulations, Title 22, Division 6 and a civil penalty for a repeat violation is being assessed. At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined and the licensee was informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49 . An exit interview was conducted and a copy of this report, appeal rights and confidential names list was provided.