Complaint·December 16, 2021

During interviews, it was established that C1 had checked on R1 10 to 15 minutes prior to the shouting. Interviews with staff revealed R1 reported being pushed down by R2, but R2 denied it. R1’s statements to medical professionals corroborated being pushed down but at that time R1 was unable to identify the person. Interviews with facility staff revealed no one saw R2 wander into R1’s bedroom, or R1’s fall. Staff interviews revealed R1 often left their bedroom door open and R2 is known to roam the halls. The facility camera was not checked, and the video only lasts 48 hours. A Med-tech came to assist and R1 was transferred to the hospital. R1 was diagnosed with a hip fracture requiring surgery. Subsequently R1 was discharged with new care orders and returned to the facility. A review of R2’s records revealed that the Licensee was working with R2’s doctor on their rapid decline and need of higher level of care. The doctor could not explain the significant decline in cognitive level in such a short period of time and was considering Hospice Care. R2 had no injuries but was transferred to UCSD for a psychiatric evaluation and did not return to the facility. Due to lack of corroborating evidence, the finding regarding the above allegation was established to be unsubstantiated. This finding means although the allegation may have happened, or could be valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with AD Robinson and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to AD Robinson via email. An electronic email read receipt confirms the documents were received.