complaint·April 8, 2022

On 02/03/2022, from 12:20pm to 1:15pm, Licensing Program Analyst (LPA) Rachael De Leon conducted the initial complaint visit. LPA De Leon met with Nereida Leal, House Manager and explained the purpose of the visit. LPA toured and took photos of R1’s bedroom. LPA requested documentation pertinent to the investigation. LPA advised the complaint was referred to the Community Care Licensing Investigations Branch (IB) and determined further investigation was needed. Investigator Munoz conducted interviews with the Reporting Party on 02/09/2022, at approximately 11:30am; with R1’s Representative on 02/11/2022, at approximately 9:02am; with Staff #1 (S1) on 02/14/2022, at approximately 7:48am, with Staff #2 (S2) at approximately 8:36am, with Staff #3 (S3) at approximately 9:12am, with Resident #2 (R2) at approximately 9:40am; with Tri-Counties Regional Center (TCRC) Service Coordinator (SC) on 03/16/2022, at approximately 3:35pm; and with TCRC Quality Assurance Specialist (QAS) on 03/17/2022, at approximately 9:12am. Additionally, Investigator Munoz reviewed Marian Regional Medical Center Medical Records, San Luis Ambulance Medical Records, 911 audio, photos, and facility file documents related to R1. R1’s facility records revealed R1 was placed at the facility on 10/04/2018. R1’s diagnoses included severe down syndrome, non-verbal, self injurious (SIB) behaviors and osteoporosis. The pre-placement appraisal information listed R1 needs help in transferring in and out of bed, uses wheelchair, and needs special observation and night supervision as R1 sometimes gets out of bed. According to R1’s Individual Service Plan (ISP), R1 uses a wheelchair, uses bilateral arm splints for self injurious behaviors and needs assistance with toileting, eating, bathing, dressing and hygiene. According to facility staff, on 01/24/2022, at approximately 2:15am, S1 heard R1’s bed alarm signal and found R1 on the floor mat next to bed. 911 records indicate S1 called 911 at 2:31am. Per the ambulance records, R1’s bed was approximately one (1) foot off the ground with a soft mat next to the bed. R1 was transported to the hospital and diagnosed with a left femur fracture. R1 had surgery on 01/24/2022 to repair the left femur fracture. Continued 9099-C On 01/26/2022, while still in the hospital, R1’s representative noted swelling on R1’s right upper extremity and wrist deformity. An x-ray of the right forearm was obtained and was consistent with right wrist volar dislocation. On 01/28/2022, a Proximal Row Carpectomy was performed on R1’s right wrist. R1 was discharged back to the facility on 02/09/2022 with a physician’s order for bed rails. A letter of support from the TCRC SC, dated 02/09/2022, was in support of R1 using the bed rails for safety. R1 had not used a bed rail prior to the order on 02/09/2022. On 02/14/2022, Investigator Munoz took photos of R1’s bed at the facility which showed a half-bed rail, a thick floor pad next to the bed, and a lowered bed. Facility staff denied any neglect or lack of care and supervision. R1’s Representative stated R1 was not neglected and facility staff provide R1 with good care. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegations. Therefore, the above allegations are deemed Unsubstantiated at this time. Exit interview and copy of report emailed to Administrator/Licensee.