complaint·December 19, 2024

On 04/05/2024, 5 staff members were interviewed. Based on staff interview, it was stated that staff check in on R1 at least 2 times per day for medications, however caregivers check in on R1 about 2 or 3 times more per shift. It was stated that there were no incidents reported for R1 on 03/01/2024. The number of times staff check in on R1, was depending on the staff. S2 stated to check in on R1 about 3 – 5 times per his/her shift. S3 states to check in on R1 at least 4 times per his/her shift. S4 states to check in on R1 about 4-5 times per his/her shift. Based on record review, on 03/01/2024, there were no progress notes written by staff on this day. On 03/02/2024, it was noted that R1 requested for pain reliver medication due to pain. From 03/02/2024 – 03/04/2024, R1 was on alert charting due to a change of condition and was being monitored for his/her pain. On 03/03/2024, staff mentioned concern that R1’s pain could be a cause of a fall. On 03/04/2024, R1 was taken to the hospital by his/her family member where R1 was seen for a swollen ankle. The review of records show that R1 is a high potential for falls but does not require assistance with ambulation, mobility, escorting, and transferring. On R1’s service plan, it states that R1’s family member has been evaluated by the community to be at risk for injury which may cause permanent disability or be life threatening. Interventions were put in place for R1’s safety, however, based on record review there was no indication on R1’s service plan that staff were required to check in on R1 every hour. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 2 of 2.