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32 | On today’s visit LPA Calderon collected staff and resident roster and conducted a tour of the physical plant alongside with Mercado. LPA and Mercado observed common areas: break room, living room, dining room and hallways were residents resides. LPA interviewed residents #2 (R2) and resident #3 (R3).
Regarding allegation: " Resident sustained injuries while in care due to lack of care and supervision." It was alleged that a facility resident who is non ambulatory and requires staff assistance with transfers to and from bed sustained bruising to the right chest area due to staff neglect and/or lack of care and supervision. It was also alleged that the resident was in a lot of pain. Based upon the department investigation, interviews with facility staff including a registry caregiver, resident #1, resident #1 family members and physician, facility residents, contact with local law enforcement and review of residents #1 facility file and medical records regarding a hospital visit on 11/25/22. The department’s investigation conducted by Investigator Douglas Real revealed the following: On 11/24/22 during NOC shift, staff #7 (S7) checked on resident #1 and noticed a small bruise on resident chest area/right side, which was the size of a half dollar coin. S7 did not observe resident #1 to be in pain or in distress at the time. On 11/25/22, at around 7AM, resident #1 family was visiting resident #1 in the facility and observed bruising on resident #1 right side chest area. Per resident #1 family member, the resident was not in any pain and was not able to recall how resident #1 sustained a bruise. Interviews with 10 of 10 staff revealed that staff did not observe resident #1 fall or sustain an injury, all staff interviewed denied knowledge of resident reporting being in any pain due to the bruising, staff denied knowledge of knowing how resident #1 sustained the bruising and staff denied harming facility residents and/or knowledge of facility staff harming facility resident(s). IB investigator Real interviewed resident #1 who did not recall how resident #1 sustained the bruise to the chest area and reported not being in pain due to the bruising. Interviews with 2 of 3 residents, including interview with resident #1 revealed that staff treat the resident well and residents did not report staff neglect or staff not providing adequate care and supervision. 1 of 3 residents reported an incident where staff allegedly violated resident’s personal rights, local law enforcement were called to the facility to investigate, and staff #8 (S8) denied the allegations. Resident #4 (R4) reported no injuries. LPA Calderon's interview with R2 and R3 are not aware of any residents who were injured due to lack of care and supervision. The investigation revealed that staff were aware of bruising to resident #1 chest area on 11/24/22 during NOC shift and on 11/25/22 during the AM shift. However, the investigation did not reveal how resident #1 sustained the bruising and there is no evidence to support the resident fell, had an accident in the facility or that staff neglected or harmed resident #1. Therefore, the allegation is deemed unsubstantiated per Title 22 Regulations, Division 6 Chapter 8.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview conducted and a copy of today’s licensing report was provided to Assistant Administrator Nilda Mercado. |