Complaint·May 23, 2023

(CONTINUED FROM LIC9099) revealed staff found R1 in a sitting position on the floor near the door of their room during rounds. There were no other persons in R1’s room when they were found. R1 was unable to explain to staff what had occurred but did complain of hip and shoulder pain and was transferred to the Palomar Hospital for evaluation where they were diagnosed with a fractured humerus as documented in R1’s Palomar Hospital medical records dated 10/20/2021. Review on 10/19/2021 IR also revealed facility staff responded appropriately, immediately requested medical attention and notified all responsible parties. Interview conducted with a member of R1’s family revealed R1 told a contradictory recollection of the 10/19/2021 incident describing how they threw a facility resident to the floor themselves rather than having been pushed out of their wheelchair. R1 was unable to be interviewed directly. Regarding the allegation “Staff neglect resulting in resident falling and sustaining a hip fracture”, it was alleged that R1 suffered an unwitnessed fall resulting in a hip fracture which contributed to their passing. Interview conducted with Memory Care Director Ana Cruz and review of Resident Incident Report (IR) dated 09/22/2022 indicated during a status check, R1 was found by staff on the floor of their room on the morning of 09/22/2022. Review of IR dated 09/22/2022 revealed R1 reported they were trying to get up on their wheelchair and fell to the floor. R1 complained of hip and back pain and was transferred to Palomar Hospital for evaluation. Palomar Hospital medical records dated 09/23/2022 indicated R1 was diagnosed with a fractured hip which was surgically repaired. Review of IR dated 09/22/2022 also revealed facility staff responded appropriately, immediately requested medical attention and notified all responsible parties. Review of R1’s Level of Care Assessment dated 07/05/2021 indicated at the time of R1’s fall on 09/22/2022, they were able to independently transfer, required no transport/escort assistance, and had been identified as a fall risk. Interview with Cruz indicated as identified as a fall risk, R1 would receive additional assistance with their Activities of Daily Living (ADLs) and more frequent status checks. None of R1’s records reviewed revealed R1 required direct supervision. Investigation did not reveal documents to corroborate nor refute staff status checks were being conducted. Following R1’s return to the facility, they were placed on hospice and passed away at the facility on 12/02/2022. Interview with R1’s hospice clinician revealed there was no evidence of “anything neglectful” related to R1’s care. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.