complaint·May 2, 2023

Interview with Staff #1 (S1) on 03/07/2023 at 10:47 a.m., and 03/09/2023 at 12:45 p.m. confirmed R1’s singular fall and mental state. Additional staff interviews on 10/12/2022, and 03/07/2023 revealed that R1 had three (3) falls on 10/04/2022. Staff stated only two (2) staff members were working that day and they helped assist R1 to their bed after two falls. After assisting R1, staff indicated they verbally let the medication technician know what happened. Further staff interviews revealed that on R1’ s 3 rd fall, 911 was contacted, and R1 was sent out to the hospital and was admitted that same day. Staff interviews also confirmed R1 did not come back to Pacifica after being hospitalized. Staff interviews also indicated that when a resident has a fall, the medication technician is notified, assess the resident and notifies the Executive Director and management of the fall. Lastly, staff indicated that they are unsure if the two (2) falls were reported to management but, on the 3 rd fall, R1 was sent out to hospital. Although ED Spitznogle and staff stated only one (1) fall was recorded and reported, additional staff interviews confirmed that on 10/04/2022, multiple staff observed R1, on 3 separate occasions, on the floor from a fall. LPA Ascencio reviewed the Incident Report for R1 dated 10/04/2022, which indicated 1 fall occurred. Additionally, a narrative charting entry and a physician commutation form was observed, both indicating that R1 had one (1) fall on 10/04/2022. Review of R1’s medical records on 03/01/2023, revealed R1’s diagnosis of sepsis, difficulty walking, muscle weakness, age-related physical disabilities, and ten (10) other medical diagnoses, according to the Physicians Report. Additionally, the Physician’s Report also indicates R1 was able to bathe, dress/groom, feed self and able to care for own toileting needs with minimal assistance. Lastly, R1’s facility assessment indicates bathing, dressing, transfer, toileting and escort require total assist from Pacifica staff. Even though, R1’s physician report indicated minimal assist with activities of daily living (ADL), Pacifica’s plan of care indicates R1 depends on staff assistance for all ADLs. R1’s discharged document, dated 09/27/2022, from a skilled nursing facility (SNF) indicated that R1 had multiple falls and was considered a fall risk. Therefore, due to R1’s facility assessment indicating total assistance with ADLs, knowledge of R1 being a fall risk from documentation, and multiple staff admitting that R1 had three (3) falls on 10/04/2022, R1 sustained multiple falls at the facility based on lack of care and supervision. Based on evidence gathered, there is sufficient evidence to support the allegation of resident experiencing numerous falls and injury(ries) at facility due to lack of supervision. Thus, the allegation is substantiated at this time. Continued on LIC 9099 - C A similar complaint was substantiated on 05/24/2022. An immediate civil penalty of $1,000.00 was assessed on 05/02/2023 due to repeat violation. 1 citation was issued. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted and copy of the report and appeal rights were issued to ED.