complaint·May 1, 2024

It was alleged that Resident #1 (R1) was escorted to their room after dinner and left in their wheelchair for a lengthy period of time, even when R1 verbally requested transfer assistance. Record review revealed that R1 does require transfer assistance and escorts. Needs and service appraisal and interview indicate that staff utilize a Hoyer lift, as well as a 2-person assist for all of R1’s transfers. In-service training records reflect that facility staff did receive training in using R1’s Hoyer lift, as well as training for R1’s service plan, which included additional status checks and transfer assistance. Interview with staff revealed that due to a personality complaint/conflict, Staff #1 (S1) was removed from R1’s direct care prior to receipt of the complaint. At the time of the alleged incident, there were 3 staff working – 1 (one) medication technician and 2 (two) care staff, including S1. As R1 is a 2-person assist, the other 2 (two) staff present were needed to assist R1 with their transfer out of their wheelchair following dinner. Interview revealed that the medication technician escorted R1 back to their room around 06:30PM, but there was no second staff available to assist with R1’s transfer at that time. R1 and staff indicated that no one returned to R1’s room until around 08:00PM, when the medication technician arrived to assist R1 with their scheduled medication. At that time again, only 1 (one) staff was present, so R1 was unable to be transferred. At approximately 08:30PM, R1’s family member arrived at the facility to discover that R1 had been transferred to their bed, instead of their recliner chair as requested. Interview with then-ED revealed that “we did blow it…per [R1]’s routine, [R1] should have been transferred back when [R1] was brought back to her room after dinner. The staff didn’t follow up after that to get her transferred.” Based on interview and record review, there is sufficient evidence to support the allegation, therefore the allegation that “staff did not provide assistance to resident in a timely manner” is deemed SUBSTANTIATED at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.