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13 | On 11/01/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Ife James, the facility Area Director. LPA met later with Direct Support Provided Fernando Garcia who signed the report.
The investigation consisted of following: Investigation visit on 11/01/23. Interviews with staff #1-#5 (S1-S5), clients #1-#3 (C1-C3), and witnesses #1-#2 (W1-W2). Record reviews for (C1’s) Face Sheet, Physician's Report, Health Care Plan, Quarterly report, Annual Progress Report, Funcitonal Capbility Assessment, Quarterly Nursing Assessment, Individial Person Center Plan (IPP); Daily Body check Log, Bladder/Sleep/Bowel Log, Incident Report, Toleting and Pericare Log, Client Roster, Staff Roster and other pertinent documents asociated with complaint. A colleteral visit at the day program and a tour of the facility was conducted.
(Evaluation Report Continues on LIC 9099-C)
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| Substantiated | Estimated Days of Completion: |
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NARRATIVE |
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32 | INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Resident fell sustaining injuries as a result of staff negligence.
The details of the complaint alleged client #1 (C1) fell and sustained injuries due to staff negligence. The complainant reported (C1) fell out of bed between 12 am - 4 am and was found on the floor due to staff neglecting to care for the (C1) properly. The complainant stated (C1) later had bruises on the high cheek bone due to the fall. The complainant reported (C1) has a bed alarm that should have been activated to prevent this fall.
The Department interviewed staff on 11/01/23 between 10:00 am - 11:30 am (4) out of (4) staff #1-#4 verified a fall incident occurred on 09/26/23. (4) out (4) reported the incident happened between approximately 11: 45 pm through 4:30 am. According to staff #5 (S5), (C1) experienced agitation and restlessness for two nights and did not have full night's sleep. According to (C1's) sleep log, (C1) slept 3.5 hours on 09/24/23, 4 hours on 09/25/23, and 7.5 hours on 09/26/23 the day that (C1) had the incident. (S4) reported being notified by (S1) by text message at 6:15 a.m. on 09/26/23 of the fall incident. (S1) did a medical assessment of (C1) at the facility and notified the primary physician, family representative, placement agency, and community care licensing. On the same day, (C1) was transported to Urgent Care at Harbor UCLA Medical Hospital for further assessment. (C1) was discharged the same day with no new medication, lab work completed, and with no acute distress noted.
An interview with witnesses between 9:00 am - 1: 33 pm (2) out (2) witnesses #1 - #2 (W1-W2) were notified by a facility staff of the incident on 09/26/23. (W1) reported noticing a face bruising on (C1) 09/28/23 prompted (W1) of the fall incident on 09/26/23. (W2) recalled being notified by (S5) of the incident and did not offer further details on how many times (C1) had fallen off the bed on 09/26/23. (W2) stated not aware that a Health Plan of Care for (C1) was in place dated 07/29/23. The Plan was implemented to prevent falls and (C1) has a history of falls and seizures. The plan included padded bed side rails; low bed position; beside foam pad on the floor to prevent injury from falls, monitor, document, and report to medical doctor signs and symptoms of seizure activity.
The Department interviewed staff #1 (S1) on 11/01/23 at 12: 37pm -12:59 pm. (S1) recalled the incident with (C1) and claimed that (C1) had multiple falls from 12:00 am - 4: 30 a.m.
(Evaluation Report continues LIC 9099-C) |
NARRATIVE |
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32 | According to (S1) the first fall happened at approximately 12: 00 a.m. and (C1) was found on the floor. Subsequent falls happened within 30-40 minutes of each fall. (S1) expressed that (C1) managed to slip out of bed each time for a total of 4 or 5 falls on 09/26/23. Each fall was assessed by (S1) and (C1) did not have any injuries that required emergency medical services according to (S1). (S1) confirmed a wired sensor bed pad alarm was in place and was working. However, (S1) stated that there have been times when the alarm was inconsistent and did not activate. (S1) stated that through the years of working at the facility, no padded beside rails nor bedside foam pad on the floor to prevent injury from falls has ever been in place. (S1) stated when the third or fourth fall happened it was approximately 3:30 a.m. and that (S1) was cleaning the a bathroom not adjacent to (C1's) bedroom. (S1) admitted the only thing (S1) could have done differently to prevent the multiple falls is to monitor (C1) in the room while sitting in a chair and watch (C1's ) activities.
A review of (C1's) Sleep Log entered by (S1) indicated, (C1) was restless and slept 3.5 hours on 09/24/23 and 4 hours on 09/25/23. (S1) indicated that (C1) slept 7.5 hours on 09/26/23 the day (C1) had multiple falls off the bed. Toileting and Pericare Log revealed (C1) was observed by (S1) at 12:00 am, 2:00 am and 4:00 am. Quarterly Nursing Assessment (dated: 10/27/23), (C1) requires continued care and support in a medically supervised facility. Attempts were made to interview clients #1-#3 (C1-C3) between 11:00 am - 11:30 am, however, due to their health condition of the clients prevented to carry full conversations.
The facility failed to provide proper care and supervision as evidenced by (C1’s) acquired injuries from multiple falls on 09/26/23. The facility failed to follow the Health Care Plan (dated 07/09/23). The facility failed to document and address (C1’s) multiple falls in progress notes and did not notify agencies that it was not a single fall but multiple unwitnessed falls. The facility failed to monitor (C1) after having two consecutive agitated and restless nights or after the first fall occurred at 12:00 a.m. on 09/26/23. The Department tested the bed alarm with (S3) on 11/01/23 at 10:50 am and observed the alarm in working condition which sounded off multiple times with a slight movement or touch.
Based on the information gathered, there is sufficient evidence of neglect/lack of care to corroborate the allegation mentioned above. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.
California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Fernando Garcia , and a hard copy of the report along with appeal rights. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Under Appeal
Type B
11/15/2023
Section Cited
CCR
85075.4(b) | 1
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7 | 85075.4 Observation of the Client
(b) The licensee shall provide assistance when observation reveals needs which might require a change in the existing level of service, or possible discharge or transfer to another type of facility.
This requirement is not met as evidenced by:
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7 | The licensee will adhere to Title 22 Section 85075.4 and agree to conduct in-service training to ensure that staff are trained to properly provide assistance and take action when the existing level of care has changed. Proof of correction must be sent to LPA by the due date: of 11/15/23 to ernand.dabuet@dss.ca.gov |
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14 | Based on interviews, record reviews, and observation, the licensee did not comply with this section. The facility failed to properly assist when observation of (C1) having multiple falls. This violation which poses a potential immediate health, safety, or personal rights risk to persons in care. | 8
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Under Appeal
Type B
11/15/2023
Section Cited
CCR
80072(2) | 1
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7 | 80072 Personal Rights (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
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7 | The licensee will adhere to Title 22 Section 80072 and agree to conduct in-service training to ensure that staff are trained to follow (C1's) Health Care Plan. Proof of correction must be sent to LPA by the due date: of 11/15/23 to ernand.dabuet@dss.ca.gov |
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14 | Based on interviews, record reviews, and observation, the licensee did not comply with this section. The facility failed to follow (C1's) Health Care Plan to prevent falls and seizure precautions. This violation which poses a potential immediate health, safety, or personal rights risk to persons in care. | 8
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