Complaint·February 16, 2022

Regarding the allegation: Due to lack of supervision, resident suffered a fall, resulting in injuries It was alleged that due to lack of care and supervision, R1 fell and sustained injuries. Interviews and a review of surveillance video revealed that on 7/16/2021, R1 was walking on the first floor with Staff #1 (S1) when R1 ran into an object inside the facility and fell over their walker. Interviews with S1 revealed that S1 believed they were approximately eight to ten feet behind R1 and alleged they kept their distance to ‘monitor’ R1. However, per the video surveillance footage of the incident, Investigator Seng concluded that S1 was approximately twenty (20) feet behind R1. In addition, video surveillance captured S1’s head facing downward towards a black object in their hand as R1 ambulated ahead of them. Due to the fall, R1 suffered lacerations to their face and a contusion to the right eye. Nursing staff believed that R1’s wounds were superficial, and placed steri-strips over R1’s wounds. Nursing staff, which included S1, ran neurological examinations throughout the night on R1 and determined that R1 did not require hospitalization. The morning of 7/17/2021, R1 became agitated and ripped out the steri-strips and dug into their wounds, causing the wounds to reopen. Staff could not stop the bleeding, so R1 was sent to the hospital. A review of hospital paperwork revealed that R1 was diagnosed with recurrent falls, sinus bradycardia, right periorbital hematoma, scalp hematoma, and fractures. Discharge notes further documented old bruising to R1’s anterior chest wall into the right upper arm, signifying ‘old right-sided rib fractures’. Lastly, it noted ‘left anterolateral 6th and 7th rib fractures’ which were documented as ‘2 new rib fractures’. Based on information obtained during the investigation, there is sufficient evidence to support the claim that due to lack of supervision, R1 suffered a fall, resulting in multiple injuries. Interviews with current and former staff, and staff from collateral agencies whom provided care for R1 noted that walking in a distance in excess of eight feet from R1 would not allow sufficient time for staff to intervene and take corrective action. Per the surveillance footage, S1 appeared to be distracted and the distance behind R1 appeared to be too significant for S1 to intervene. This allegation is deemed Substantiated at this time. Regarding the allegation: Facility did not seek medical attention in a timely manner. It was alleged that R1 should have been sent to the hospital following their fall the evening of 7/16/2021, as R1 struck their head. Staff interviews revealed that staff decided against sending R1 to the hospital as R1’s wounds appeared to be superficial, and nursing staff were monitoring R1 throughout the night. Interviews confirmed that staff placed steri-strips on R1’s wounds and assessed R1 thoroughly and were unable to identify any immediate health and safety concerns. R1 was then placed in their room and was monitored throughout the night. The morning of 7/17/2021, R1 became agitated and ripped out the steri-strips and dug into their wounds, causing the wounds to reopen. Staff could not stop the bleeding, so R1 was sent to the hospital. A review of hospital paperwork revealed that R1 was diagnosed with recurrent falls, sinus bradycardia, right periorbital hematoma, scalp hematoma, and fractures. Discharge notes further documented old bruising to R1’s anterior chest wall into the right upper arm, signifying ‘old right-sided rib fractures’. Lastly, it noted ‘left anterolateral 6th and 7th rib fractures’ which were documented as ‘2 new rib fractures’. Interviews with facility staff, hospital staff, and collateral agencies confirmed that whereas nursing staff were overseeing R1’s care immediately after the fall, they were unable to assess whether R1 had any internal injuries that were not assessable via a neurological assessment. Interviews and surveillance footage confirmed that R1 fell headfirst; R1 could have suffered a brain bleed or other injuries unbeknownst to staff. If R1 hadn’t ripped out their steri-strips the morning after the fall, the facility may not have taken R1 to the hospital, and the facility would have been unaware of R1’s additional injuries. Based on the information obtained during the investigation, there is sufficient evidence to support the claim that facility did not seek medical attention for R1 in a timely manner. This allegation is deemed Substantiated at this time. A Civil Penalty in the amount of $500 was assessed during today's visit. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided via email for signature, along with appeal rights. Regarding the allegation: Resident was left in soiled clothing It was alleged that R1's incontient needs were not met, resulting in staff leaving R1 in soiled clothing. The investigation revealed that on the evening that R1 suffered a fall, R1 was accompanied by a caregiver from an outside agency. One caregiver worked with R1 from 9:00 p.m. and left on 7/17/2021 at 6:00 a.m., and the other caregiver came on shift to work with R1 on 7/17/2021 at approximately 7:55 a.m. In addition to the caregiver assigned to work with R1 through the night, R1 was regularly checked throughout the night by facility nursing staff. Interviews revealed that from the hours of 6:00 a.m. to 8:00 a.m., facility staff were responsible for tending to R1’s care needs. Records review indicated that R1 was checked by facility staff at 7:30 a.m., and R1 did not appear distressed, unwell, or soaked in urine. Records review and interviews indicate that R1 pulled out their steri-strips between 7:30 a.m. – 8:00 a.m., to which at that point, R1 was sent to the hospital. Staff interviews revealed that residents are checked on at least every two hours to ensure that incontinent needs are met timely. Staff agreed that at times, some residents refuse to be changed, but they try multiple intervention methods to ensure that resident needs are tended to in a timely manner. Interviews revealed that staff are responsive in meeting the toileting needs of the residents and are communicative with one another if they need assistance with changing or refreshing a resident. Lastly, interviews revealed that residents are regularly checked for skin breakdown or the presence of wounds, which none of the residents have at the time of this visit. Based on the information obtained, there is insufficient evidence to support the claim that due to lack of care and supervision, R1 was left in soiled clothing. R1 was checked within the two hour window prior to being hospitalized. Despite being checked and refreshed within a two hour time frame, R1 - or any resident - can soil their clothing soon after being checked. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.