Incident investigation·May 13, 2024

On 5/10/2024 Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced case management visit to the facility for incidents of unwitnessed and witnessed falls. R1 had a witnessed fall on 5/1/2024, R1 was taken to the ER and was diagnosed with a fracture of the Tibial Plateau. R1 returned to the facility on hospice. R1 service plan dated 4/16/2024 confirmed that R1 was a two person assist with transferring. Based on the incident report dated 5/7/2024, R1 was transferring from the recliner chair to the wheelchair and fell. R1 was being assisted with transferring by S1, the facility did not have as assessed a second person to assist with the transfer and as a result R1 fell and sustained a fracture. R2 was sent out on 4/13/2024 for evaluation from feeling sleepy and lethargic. During the review of the file the department discovered that R2 had a fall on 4/15/2024 witnessed by R2's wife and reported to the facility. R2 was sent out to the ER at St. Joseph's hospital. The discharge summary listed the chief complaint as a fall yesterday(4/15/2024) w/subdural hemorrhage. R2 was discharged and scheduled to see the primary care physician on 5/8/2024. R2 did not return to the facility after April 15th 2024. Continued R3 had an unwitnessed fall and was sent out to San Joaquin General ER. R3 was diagnosed with a Hematoma to the forehead. R3 was to follow-up with primary care physician. During the review of the file the department observed an outdated Physician's report. (LIC 602 4/27/2024). Deficiencies are cited on 809-D, per Title 22 Regulations, Division 6. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87464(f)(1) . The licensee was informed that an enhanced civil penalty (ECP) was pending review and may be assessed according to Health and Safety Code 1569.49(f). Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties. Exit interview was conducted. Appeal rights given.