complaint·November 28, 2022

[CONTINUED FROM LIC 9099] Per outside interviews, their LIC602 Physician’s Report, and their Care and Service Plan, R1 was in an early stage of cognitive impairment but still “able to follow instructions” and “able to communicate [their] needs.” CCLD interviewed R1 and verified they were a credible witness. R1 was alert and oriented to self, others, place, and time. R1 was articulate and self-aware, able to describe their current physical and cognitive condition, their likes and dislikes, and their life story. R1 affirmed knowing and remembering who S1 was. R1 said S1 never touched their breasts or any other part of their body in a sexual manner, nor did they tell anyone such. R1 said their breasts still hurt, six months after they moved out of the facility, concluding, “I think I have breast cancer.” S1 also denied the allegation. S1 said they were administrative staff and thus not hands-on with any aspect of R1’s personal care. Interviews of multiple facility caregivers and review of the facility’s care task logs corroborate S1 did not personally bathe, dress, or toilet R1; caregivers instead completed these tasks. The complainant admitted there were no witnesses to the alleged incident with R1. All staff interviewed said they never saw S1 inappropriately touch R1 or any other resident. The San Diego County Long Term Care Ombudsman’s Office (LTCOP) reviewed the alleged incident, advising CCLD that they found no evidence of wrongdoing. CCLD observed the bedside device described by the complainant, determining it was a pressure-activated bedside alarm/alert mat, a tool not expressly prohibited by California Code of Regulations or California Health and Safety Code. According to a March 2019 study titled “Alarming and/or Alert Device Effectiveness in Reducing Falls in Long-Term Care (LTC) Facilities? A Systematic Review,” published by the National Institutes of Health ( www.nih.gov ), alert devices “can assist in the care and safety of nursing facility residents…when used as one piece of a comprehensive care plan…” and “can be quite effective devices in ensuring resident safety.” [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Per their LIC602 Physician’s Report and their Care and Service Plan, R1 was “recovering from a left hip fracture” and was a “fall risk.” R1 had impaired eyesight, required staff assistance with transferring in/out of bed, and needed a combination of walker and/or wheelchair for mobility. Interviews of facility staff, outside sources, and R1 themselves showed that R1 had a history of falls. Per LIC624 Incident Reports licensee previously submitted to the CCLD San Diego Regional Office (RO), R1 had three falls from April 2021 through August 2021. In their interview, R1 said they liked having a bedside alarm/alert mat because “it makes me feel safer.” When R1 was asked if the mat was too large, R1 said, “No.” When asked if the mat caused them to feel their restrained or unable to leave their room, they said “No.” Multiple caregivers corroborated that while R1 lived at the facility, they never complained about the mat or of feeling restrained. The LTCOP also reviewed the alarm/alert mat allegation, concluding that it did not infringe R1’s personal rights. Based on records and interviews, the allegations that S1 touched R1’s breasts or that Licensee’s use of a fall mat restrained R1’s movement are unfounded, meaning they were false and/or without a reasonable basis. We have therefore dismissed both allegations. An exit interview was conducted with the Ancho, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided. [CONTINUED FROM LIC 9099] Per the LIC624 Incident Report (which licensee submitted to the CCLD San Diego Regional Office on the day after the incident): during the early morning of 08-01-2021, R1 fell in their bathroom. R1 described pain and “soreness in [their] back,” leading facility staff to send them to the hospital ED. The licensee then sent a text message via cell phone to R1’s responsible party (RP) around 6:15 AM. RP phoned S1 back around 8:20 AM, relaying updates on R1’s condition from the hospital staff. According to hospital records, R1 sustained a thoracic vertebral compression fracture and a lumbar vertebral compression fracture, but no surgery was required. In their interview, the licensee reiterated the above timeline, and provided CCLD a date and time-stamped screenshot of the text message they sent to the RP. In this 6:15 AM text message, the licensee wrote that R1 fell in the bathroom, their back was sore, and that paramedics had been called. (The text message did not indicate if R1 had been transported to the hospital.) In their interview, Caregiver Staff #2 (S2) corroborated that the licensee indeed notified RP about the incident. During an unannounced site visit on 02-24-2022, LPA inspected and photographed the contents of the facility’s refrigerator and a nearby countertop. LPA observed red grapes, cut watermelon, Roma tomatoes, romaine hearts, celery hearts, zucchini, bell peppers, carrots, tangerines, orange juice, and yogurt with cut strawberries. All fruit and vegetables were reasonably fresh and stored in safe packaging. CCLD also reviewed the facility’s written food menus for the two weeks preceding the filing of the complaint. The menus show residents were served three meals per day, and no same dish was repeated from one day to the next. The dishes showed balance between carbohydrates, proteins, fruit, and vegetables. This two-week menu excerpt included these specific side dishes: fresh mixed fruit, peas, carrots, green beans, cauliflower, zucchini, oranges, corn, sweet potatoes, and different kinds of salad. The licensee and multiple caregivers consistently affirmed that fruits and vegetables are served as part of the menus. The San Diego County Long Term Care Ombudsman’s Office reviewed their prior visits to the facility, advising CCLD they had no concerns, and received no prior complaints, regarding the nutritive value of the food served at the facility. Based on interviews and records, the preponderance of evidence shows facility staff notified R1’s responsible party of R1’s 08-01-2021 fall, and fruit and vegetables are served to residents in care. Both allegations are therefore unsubstantiated. An exit interview was conducted with Ancho, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.