Complaint·November 26, 2024

(Continued from LIC9099 p.1) Staff involved in the incident informed that the facility policy regarding falls with evidence of a head injury required the initiation of emergency services. These same staff acknowledged that 911 services were not initiated per protocol and that it should have been done. Outside source interviews corroborated staff interviews, informing that upon arriving to the facility, the outside provider contacted R1's physician and then 911 approximately one (1) hour after R1's fall. Outside sources confirmed that evidence of a head injury existed due to R1 having a forehead wound, which was covered by a bandage. The Unusual Incident/Injury Report submitted by the facility regarding the incident corroborated interview statements that the outside source contacted 911 for further evaluation of R1 after the fall. Review of facility document, "Falls Quick Reference Guide", revision date December 2013, stated, "If a licensed nurse is not immediately available, observe the resident for the following: ...The resident tells you, or was observed, or it appears, that they hit their head...If any of the above signs are present - Do not move resident, call 911 immediately". Staff knowledge and understanding of this rule was confirmed through interviews. Review of R1's hospital admission records the day of the incident showed that R1 was admitted for evaluation after a fall with head injury. The medical records showed that R1 was assessed to have a closed head injury and abrasion. These records confirm that staff did not follow facility protocol regarding falls with evidence of a head injury. While R1 ultimately did receive 911 medical care, the initiation of assistance was due to the outside provider who visited R1 the day of incident, not facility staff. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Interim Executive Director Kathleen Olson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) R1's Physician's Report dated 12/2/2020 revealed that R1 was "Able to feed self” and did not indicate that R1 needed help with tasks such as using their cell phone. These documents do not corroborate the allegation, as they do not show an expectation that staff were responsible for feeding R1 or assisting with the use of R1's cell phone. Staff interviews were consistent regarding R1's assistance needs. Staff informed that R1 required assistance with Activities of Daily Living (ADLs), specifically noting transferring in and out of bed to wheelchair, dressing, toileting and bathing. Interviews with staff regarding services provided to R1 were consistent with R1's needs listed in the Physician's Report and facility assessment. Staff interviews did not provide corroboration to the allegation. During interview R1's Responsible Party did not corroborate the allegation. R1's Responsible Party stated that facility staff did a wonderful job caring for R1, and that R1 was thriving at the facility. Interview with R1 did not corroborate the allegation. R1 informed that staff treated them well and did not inform of any services denied to them by facility staff. Regarding the allegation, "Facility staff did not provide client supervision resulting in injuries", it was alleged that staff neglect resulted in R1 falling seven (7) to ten (10) times during the timeframe of complaint. Staff and outside source interviews did not corroborate this allegation, informing that R1 had never fallen from a standing position due to not being able to walk or stand without assistance. Review of facility records did not corroborate that the resident fell 7-10 times. Evidence shows that the resident fell once on 12/11/2020, suffering a head injury without immediate 911 initiation from staff. This incident was investigated by the Department and the facility was cited for failure to assist with medical care. During interview the reporting party admitted that they did not directly witness the alleged falls and had not found R1 on the floor or with injuries, with the exception of R1's fall on 12/11/2020. Outside sources further revealed that R1's claims of falling may have been a hallucination due to a medical condition. Review of R1's Physician Report and facility assessment showed that R1 required assistance with transferring in and out of bed to wheelchair, bathing, and specific Activities of Daily Living (ADLs) such as putting on pants. No records were found to show that facility staff neglected to consistently provide these services to R1. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) During interview R1's Responsible Party did not corroborate the allegation. R1's Responsible Party stated that facility staff did a wonderful job caring for R1, and that R1 was thriving at the facility. Interview with R1 did not corroborate the allegation. R1 informed that staff treated them well and did not inform of any numerous falls or lack of supervision by facility staff. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Interim Executive Director Kathleen Olson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.