complaint·February 9, 2023

On 10/14/2022, Investigator Real conducted an interview with staff, on 10/25/2022, with R1, Resident #2 (R2), and staff; and on 12/06/2022, with staff. Additionally, Investigator Real reviewed hospital medical records and the Unusual/Injury Incident report related to R1. A summary of the Unusual/Injury Incident report dated 09/01/2022, indicated facility Staff #1 (S1) observed R1 “walking down the hallway” when R1 stumbled and fell. R1 was in pain, S1 called 911 for paramedics. Paramedics arrived and rolled R1 onto back which allowed S1 to see R1’s face was swollen, and lip was bleeding. Paramedics transported R1 to St. John’s Medical Center for evaluation. R1 returned to the facility the same day with a diagnosis of bruising to right eye and a fractured right humerus (shoulder). A review of the St. John’s Medical records revealed on 09/01/2022, R1 was transported by ambulance and admitted to the emergency department at 1:55pm after a fall at the facility. A physical exam found mild bruising around R1’s right eye. An x-ray of R1’s right shoulder found an acute comminuted fracture of the right humeral head and neck with valgus angulation (shoulder fracture). R1’s right arm was placed in a sling and an orthopedic evaluation was ordered. R1 was discharged from the hospital back to the facility the same day. On the allegation “Neglect/Lack of Supervision – Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) falling and sustaining a fracture” - Information obtained through interviews found that R1 was unable to provide any detail as to the fall. The staff advised that R1 is a fall risk if they walk without an assistive device. R1 uses a walker when ambulating and needs frequent reminders and prompts as R1 often forgets their walker. S1 witnessed R1 ambulating alone down a hall without their walker and fell face first. One of the staff heard the victim fall and immediately checked on the sound and observed R1 on the floor and R1’s walker was nowhere in sight. Prior to the fall, R1 had been in the activity room with the other residents and two staff supervising the residents. One of the staff in the activity room took a resident to the bathroom leaving only one staff to monitor the residents. At some point, R1 managed to leave the activity room undetected by the staff and ambulate without their walker more than twenty feet down the hall and around a corner to where they fell. (continue to LIC9099c) R1’s hospital records indicated R1 sustained a bruised right eye and a right humerus (shoulder) fracture as a result of the fall. The information and evidence obtained sufficiently supported the allegation, therefore, the allegation is deemed substantiated at this time. A $1000 immediate civil penalty is warranted for a repeat violation of the same section and subsection cited within a year on 11/29/2022. The Executive Director 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.