complaint·April 10, 2025

Due to staff negligence, resident has had multiple unwitnessed falls. - SUBSTANTIATED It was reported that during rounds staff has found Resident 1 (R1) on the floor three times while motion detectors were supposed to be in place and being properly monitored and responded to by staff. LPA reviewed staff schedules for the month of January 2025. In the memory care unit, there were two care staff and 2 med techs serving both sides of the facility for all shifts. LPA reviewed care plan for Resident 1 (R1) which states that staff is to check on R1 four times per night at 12:00 AM, 2:00 AM, 4:00 AM, 10:00 PM, as needed. Staff are to assist resident to the restroom during nighttime checks to prevent falls and reposition as needed. Ensure resident has nonskid socks on all night and verify bed alarm is turned on at all times when resident is in bed. R1 has been using various forms of fall alarms (pressure alarms, motion detectors) since March 2024. LPA reviewed the following incident reports related to Resident 1 (R1): 02/23/2023 12:09 AM R1 was found on their back in the bathroom by care staff while doing rounds. R1 was complaining of back pain and was sent to the ER for further evaluation. R1 was admitted to the hospital for treatment of acute urinary tract infection, acute left closed rib fracture. This incident occurred before R1 started using an alarmed monitor of any kind. 07/20/2024 1:30 AM care staff heard R1 calling for help. Staff found R1 in their bathroom on the floor. A Med Tech examined R1 for injury and found that R1 had two minor cuts to their right elbow. Med Tech provided first aid. 01/05/2025 10:30am R1 was found on the floor by care staff doing rounds for shift change. R1 transported to ER and examined. There were no acute findings noted. R1 returned to the facility the same day for continued monitoring and R1 was moved closer to the common area and med tech room. Continued on LIC9099-C On 01/28/2025 LPA conducted a case management visit at the facility related to a staff member who was terminated for turning motion detector sensors away from the beds of residents who are at risk of falling. LPA confirmed that this staff started working at the facility on 11/15/2024 and was terminated from employment on 01/22/2025. LPA reviewed staffing schedules for the month of January 2025 and confirmed that this staff did not work in the memory care unit of the facility on 01/05/2025 which is the date of a reported unwitnessed fall for R1. This staff was not employed by the facility on 02/23/2023 or 07/20/2024 when the two prior unwitnessed falls occurred for R1. R1 has had three unwitnessed falls over the course of three years. One of the falls occurred prior to the facility implementing motion detectors / pressure alarms for R1. Two of the falls occurred after the use of motion detectors / pressure alarms for R1 were implemented. On 07/20/2024 staff heard R1 calling for help and on 01/05/2025 staff found R1 on the floor during rounds. There is no mention of staff hearing or responding to motion or pressure alarms in either of these incident reports. Staff interviewed stated they can clearly hear the alarm when a motion sensor or pressure alarm is triggered. There is no reasonable explanation as to why staff did not respond to installed motion sensor and pressure alarms to assist the resident as soon as the resident got out of bed and instead found the resident on the floor on these dates. LPA has not determined that staff were necessarily negligent, but has determined that staff require more training related to the use of fall monitors and pressure alarms. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell. Licensee does not ensure resident's fall monitors are in good repair. - UNSUBSTANTIATED It was reported that motion detectors and receiving equipment are not being properly installed, adjusted, and maintained. 02/10/2025 During an unannounced visit Licensing Program Analyst (LPA) Rebecca Knight toured the facility and inspected motion sensor and pressure alarms in the memory care unit. There are a total of two rooms with motion sensors and one bed that has a pressure alarm. LPA observed noise boxes located at the top of the fire doors in the unit. When LPA entered room 201 and moved in front of the motion detector the noise box sounded an alarm. When LPA entered room 203 LPA observed a bed to the right of the room. Administrator pulled back the covers and a pressure alarm was present. Administrator pushed down on and lifted her hand and LPA heard an alarm sound. LPA entered Room 215 and observed a motion detector, When LPA moved in front of the motion detector the noise box sounded an alarm. LPA reviewed care plan for Resident 1 (R1) which states that staff are to verify bed alarm is turned on at all times when resident is in bed. All staff interviewed confirmed that they can clearly hear the alarm when the pressure alarm or motion sensor detectors are triggered. Administrator stated it is in the resident care plans for the staff to check the motion detectors and pressure alarms every shift and the maintenance director checks the batteries and noise boxes every day. It was determined that the motion sensors and pressure alarms are properly installed and maintained. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to administrator Nicole Braswell.