Complaint·January 7, 2025

It was alleged that resident sustained pressure injuries due to neglect. The investigation included interviews with facility staff and a review of records. LPA Truong interviewed 6 facility staff members. Two of the staff stated that (R1) may have had skin injuries but could not recall or confirm any such injuries. The records review revealed that R1 was under hospice care with Bristol Hospice. According to Bristol Hospice records, R1 was seen by a hospice nurse, with visit summaries from 09/08/22, to 09/23/22. A hospice notes from 09/14/22, indicated that R1 had a pressure injury in the posterior lumbar area that appeared to be a stage two injury, which had healed or 100% epithelialized. A registered nurse performed wound care for R1. Additionally, a hospice notes from 09/21/22, confirmed that the wound on the R1’s buttocks was fully healed. R1 was discharged from Bristol Hospice on 09/23/22, due to being outside the service area. On 10/25/22, R1 began receiving hospice services from Accent Care. Based on the interviews and statements gathered during the investigation, LPA was unable to corroborate the allegation. It was alleged that staff did not seek timely medical attention for resident in care. This investigation consisted of records reviewed. It was learned that on 09/23/22 (R1) was transported to Methodist Hospital of Sacramento for a chief complaint of right hip pain and impaired mobility. The radiology report stated that R1 sustained an impacted fracture over the right femoral neck due to a possible fall. There are inconsistent statements from staff regarding whether R1 sustained a fall resulting in the hip fracture. There are no direct witnesses, and it is unclear when the possible fall may have occurred. Furthermore, hospice records indicated Regency Place did not report any falls to hospice staff. Hospice staff also assessed R1 multiple times between 09/08/22 and 09/21/22 and no pain or discomfort was noted. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA was unable to corroborate the allegations. It was alleged that the resident sustained unexplained injuries while under care. The investigation involved interviews with facility staff and a review of records. LPA Truong interviewed 6 facility staff members. One staff member stated that they "think" the resident had a fall and was taken to the hospital. However, there were inconsistent statements from staff regarding whether R1 fell and sustained injuries. Additionally, there were no direct witnesses who could confirm that R1 had sustained injuries while in care. A review of the hospice records revealed that Regency Place did not report any falls to the hospice staff. Based on the interviews and statements obtained during the investigation, LPA was unable to corroborate the allegation. Continued LIC 9099-C The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was held, and a copy of the report was provided at the end of the visit.