Complaint·December 29, 2021

Interviews revealed OS1 asked R1 what happened that caused the bruising and R1 replied that the bruising was the result of a fall. R1 stated “I fell back” but was unable to provide any more information due to their limited ability to communicate. A record review revealed on September 14, 2021 R1 was taken to A1's clinic for a routine visit. The medical update from the visit notates mild bruising possibly due to blood thinner. Interviews with facility staff and a record review revealed no knowledge or any documentation of R1 sustaining a fall, or ever being found on the floor in need of help. An interview with facility Staff2 (S2) revealed R1 was a 2 person assist. S2 assisted R1 with transfers in and out of their bed. S2 stated R1 would not have been able to get themselves back up after a fall due to their paralysis. An interview with the Primary Care Physician (PCP), that had treated R1 since 2013, revealed if R1 had a fall from a wheelchair they would be unable to extend their right arm to block the fall due to paralysis of the right side of R1’s body. An interview with the Licensee revealed during this time, R1 spent most of their time in bed and had facility staff repositioning R1 every 1-2 hours, if facility staff had known about a fall, they would have sent R1 to the hospital for an examination. R1's care plan did not include a fall risk plan because R1 did not have a history of falls. It was also alleged that facility staff did not seek medical care for R1. On August 26, 2020, R1 complained of arm/shoulder pain to facility Staff1 (S1) who then observed bruising to R1's shoulder/arm area. An interview with S1 revealed on that same day S1 reported the incident to the Medical Agency1 (A1) that had been responsible for all R1's medical care since 2010. A record review revealed R1 was taken to a routine visit to A1 and A1 staff advised S1 that the bruise/pain was due to a blood thinner medication R1 was taking and to provide pain medication to help provide relief. A record review revealed on September 17, 2020 A1 staff came to the facility to observe R1 and ordered Physical Therapy (PT) and pain medication. The following day, September 18, 2020, A1’s mobile X-Ray unit came to the facility and took an X-Ray of R1’s arm, and on September 21, 2020 A1 notified the facility that R1 had an acute humerus fracture to their right arm and would require wearing a sling. The investigation revealed no evidence to determine the cause of the fracture. Due to lack of corroborating evidence, the finding regarding the above allegations were 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 Licensee Cho and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Licensee Cho via email. An electronic email read receipt confirms the documents were received.