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32 | Regarding Allegation #2: this investigation revealed that Resident #1 sustained an unwitnessed fall in their room on the morning of 09/13/21; whereby Resident #1 was discovered on the floor by Staff #3 (Caregiver). Staff members assessed Resident #1 at that time and did not observe visible injuries. Resident #1 did not complain of pain and declined emergency medical services to Staff #3. Staff #5 (Caregiver) checked on Resident #1 at 6:45 a.m. (before end of shift) and Resident #1 was still sleeping. Staff #4 (Caregiver) observed Resident #1 watching T.V. Staff #3 stated that R1 was able to move around on their own and used a walker for assistance. Staff #3 checked on R1 around 7:30 a.m. and the resident was still in bed. Staff #3 went back to R1's room (approximately) 8:30 a.m. and found R1 on the floor in a sitting position; but, R1 had not expressed pain. Staff #3 stated as R1 was trying to get up on their own, S3 told R1 not to move because facility staff was calling 9-1-1. Staff #3 stated facility staff helped R1 off the floor and assisted them to the bathroom. Staff #3 stated that R1 had breakfast and lunch with no problem; however, after lunch, R1 complained about chest pain and shortness of breath and facility staff immediately called 9-1-1. Administrator confirmed that R1 had breakfast and lunch that day and did not complain about shortness of breath until 1:00 p.m. After R1 began to complain of having chest pain and shortness of breath, facility staff called 9-1-1 and the resident was transported to St. John Hospital. Once at the hospital, it was discovered that Resident #1 had sustained multiple rib fractures. Administrator stated that R1 was not a fall risk. [A review of the Physician's Report (dated 07/26/21) does not document that R1 is a fall risk. A review of the Pre-placement Appraisal Information (dated 07/20/21) documents "can stand up and walk w/assistance (walker)."] On 09/15/21, Resident #1 was transferred to Rehab Center of Santa Monica for physical therapy/ occupational therapy needs; however, the resident caught pneumonia. The medical report indicated that the multiple “unhealed” left rib fractures and right rib fractures were chronic. Resident #1 ultimately passed away on 09/19/21 while in the medical care at the Rehab Center of Santa Monica.
Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/ LACK OF SUPERVISION: Facility failed to provide medical services in a timely manner is found to be SUBSTANTIATED.
According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Civil Penalty assessed.
No exit interview conducted as the facility closed its doors, effective 08/30/22. This complaint investigation report will be sent to Licensee (via USPS Certified Mail Receipt #7018 1830 0000 6864 2035).
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