Inspector’s narrative
What the inspector wrote
(MCD) Amber Silverman, LVN and explained the reason for the visit. At approximately 09:35am, LPAs met with the MCD; at 10:05am, LPAs interviewed Resident #1 (R1); at 10:29am, LPAs met with Health Services Director Sylvia Williams, LVN; at 10:55am, LPAs conducted an interview with a visitor. At approximately
10:15am, LPAs conducted a brief tour of memory care and the main lobby area of the facility. LPAs obtained pertinent documents at approximately 12:15pm. LPAs determined further investigation was needed prior to issuing findings.
On 07/19/2022, at approximately 2:00pm, Investigator Santana conducted an interview with R1’s resident representative; on 07/20/2022, at approximately 1:50pm, attempted to conduct an interview with R1, however, due to R1’s lack of orientation to person and place, was unable to conduct interview, at approximately 2:10pm, with R1’s roommate; on 07/26/2022, at approximately 4:00pm, with facility staff; on 08/17/2022, from approximately 12:35pm to 4:30pm, with facility staff; on 08/18/2022, at approximately 12:20pm with Hospice case manager; on 08/22/2022, from approximately 8:15am to 5:05pm, with facility staff and former facility agency staff; on 08/30/2022, at approximately 7:20am, with facility staff; on 09/06/2022, at approximately 4:00pm, with hospice RN; on 09/07/2022, from approximately 12:20pm to 9:55pm, with Hospice manager and facility staff, at 3:30pm attempted interview with former facility staff #1 (S1) and again on 09/16/2022, but received no response; on 09/08/2022, from approximately 10:35am to 4:00pm, with facility staff, former facility staff, facility agency staff, hospice RN and MCD, at 12:00pm attempted interview with former facility agency staff #2 (S2) and on 09/14/2022 and 09/16/2022 attempted again to conduct interview with S2. Additionally, Investigator Santana requested and reviewed hospital medical records, hospice records, Ventura County Fire Department records, and facility file documents including incident reports, progress notes, and facility staff schedule. The Oxnard Police Department informed Investigator Santana there were no reports taken concerning R1. The Ventura County Long Term Care Ombudsman Program (LTCOP) were contacted and confirmed they were aware of the present allegation.
(continued on 9099-C)
On 05/15/2020, R1 was admitted to the facility with a diagnosis of Alzheimer’s dementia and a history of osteoporosis. R1 was able to ambulate on their own but also had a walker. After some falls in December 2021, R1 began using a wheelchair and became wheelchair-bound when physical therapy did not allow R1 to regain the ability to ambulate. R1 was placed on hospice services as of 01/03/2022 and received half bed rails and a fall mat on 01/20/2022. The bed alarm ordered by hospice on 05/23/2022, was not put in place because, per the MCD, the facility considered it a restraint. In addition, for fall prevention measures, the facility equips each room with motion sensors to alert staff members when there is movement. When the sensors are activated, a signal is sent to the pagers, but the pagers either broke or went missing. Per the MCD, new pagers were acquired in September 2022. Prior to that there was only
one pager and the person who monitored the pager was supposed to notify caregivers over the walkie-talkie whenever there was motion.
According to R1’s hospice and facility shift notes, on 11/16/2021, a fall in courtyard, bruise to right eye was noted; on 12/02/2021, a fall at 5:30pm, fractured clavicle; on 12/14/2021, fall in the morning; on 01/20/2022, half bed rails, fall mat delivered; hospice informed staff to place fall mat on floor; 02/24/2022, staff told hospice that R1’s roommate tells them when R1 gets up on their own; 05/18/2022, fall, found sitting on floor by morning staff, bed rail was engaged; 05/23/2022, fall at 6:20am, pain on right wrist; facility notified hospice at 6:37am; 05/25/2022, hospice noted black and blue marks on right eye; 05/27/2022, hospice observed bruises on left arm and right leg.
On 05/23/2022, R1 was admitted to the hospital at 10:17am after arrival via ambulance following right wrist swelling from a possible fall. The facility reported that R1 was found on the floor that same morning at 6:00am. An X-ray of the right wrist showed a comminuted fracture through the distal radius including a horizontal component through the metaphysis and vertical component extending up to the articular surface. R1 was placed in a forearm splint.
On the allegation: Staff do not treat residents with dignity which resulted in R1 sustaining a fractured right wrist after a fall from bed due to staff neglecting to R1’s wishes to get out of bed. R1 is a known fall risk and sustained several falls at the facility in December 2021, one of which resulted in a fractured clavicle. After
(continued on 9099-C)
each incident, the appropriate notifications were made and medical treatment sought, and while steps were taken to prevent the recurrence of falls, these measures were not always fully carried out. R1 was issued a fall mat by hospice on 01/20/2022, but it was often not placed on the floor next to R1’s bed, despite instructions from hospice on 01/20/2022 that this be done when R1 lies in bed. Each resident room is equipped with motion sensors, but the pagers that receive the notifications were misplaced for about one year and were not replaced until September 2022, rendering them useless. On the morning of 05/23/2022, R1 was found on the floor with pain to right wrist at 6:15am after being put back in bed at 6:00am as R1 sat at the edge of the bed below the area secured with a half bed rail. The MCD stated
R1
should not have been put back in bed if R1 was already awake because R1 is a fall risk. R1 had last been found on the floor next to the bed on the morning of 05/18/2022. Staff admitted to being unaware R1 required the use of a fall mat prior to 05/23/2022. In addition, the MCD stated that the bed alarm ordered by hospice and delivered on 05/23/2022, following R1’s fall, was not put in place because the facility considers it a restraint. There is sufficient evidence to show the facility was not making use of all of its fall precautions for R1, thereby failing to safeguard R1’s health and safety. The allegation that facility staff do not treat residents with dignity which resulted in R1 sustaining a wrist fracture as a result of facility staff neglecting R1’s wishes to get out of bed is therefore Substantiated.
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A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).
Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.
Please refer to the LIC 9099 issued on 5/4/2023 for the report.
Please refer to the LIC 9099 issued on 5/4/2023 for the report.
