complaint·February 20, 2024

Page 2 of 3. On 8/7/2023, from about 2am - 6am, R1 had 2 (two) unwitnessed falls in his/her room, where R1 was found on the floor or sliding off the bed. On 8/14/2023, the Department received an Incident Report dated 8/7/2023, stating at about 6:00am staff observed half of R1’s body hanging off the bed, leaning on the right side. R1 was repositioned in bed and R1 did not have any pain. On 8/21/2023, the Department received an addendum to the Incident Report for 8/7/2023 stating R1 was observed at about 2:00am on the floor next to his/her bed in a sitting position during safety check rounds. Staff did not observe any injury and 2 staff assisted R1 back to bed. Report stated staff did not document the incident and the facility conducted in-service training on 8/19/2023. Based on record review of R1’s file, R1 has a history of falls which have been sustained before and after being admitted to the facility. Based on Physician’s Report dated 6/17/2022, R1’s other conditions were listed as “repeat falls” per physician’s notes. R1’s Services Plan dated 5/10/2023, R1 had a history of 9 falls within the year 2022 and episodes of increased confusion, hallucinations, and weakness. R1 requires daily dress/undressing, bathroom twice a week, routine bathroom assistance, and wheelchair escort. The Services Plan does not address R1’s fall-risk behaviors. Based on interviews conducted on 8/16/2023 with 4 staff (S1-S4), 4 out of 4 staff stated R1 had a history of falls and needed 2 person assistance for Activities of Daily Living (ADL), which included bathing, dressing, and toileting. 4 out of 4 staff stated R1 needs bed rails to help assist with falls. Based on an interview with Resident Services Director (RSD) on 8/17/2023, R1 did not need fall prevention precautions but R1 would benefit from them. Per RSD, R1 used a half-bed rail and R1 is on 2-hour safety checks conducted by staff. After the incident occurred on 8/7/2023, R1 was admitted to the hospital from 8/7/2023 through 8/11/2023. Based on R1’s hospital notes, the reports stated the hospital conducted X-rays of R1's knees and ankles. The impressions of the knee discovered a “comminuted distal femur fracture above the right knee prosthesis. The impression of the ankles were “chronic appearing and severe degenerative changes throughout the ankle. No gross fracture”. Per discussion of the hospital physicians, based R1's advance dementia and prior low level of function, surgery was not appropriate. Based on review of R1’s interdisciplinary Notes, R1’s responsible party updated facility of R1’s condition, stated R1 sustained a fracture in R1’s knee, R1 would not return to his/her normal baseline and R1 would become bed bound. Page 3 of 3. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with LVN Residential Manager, Fidel Manuel and a copy of the report was provided.