According to complainant, R1 suffered from three (3) falls after R1 tripped over the tape rubber molding placed between the living room and kitchen area. First fall was on 8/9/22, second fall was on 8/14/22, and third and final fall was on 1/2/23. At approximately 6:15 a.m. on 1/2/23, R1’s responsible party (RP) received a phone call from the facility that R1 had another fall around 1:30 a.m. on 1/2/2023, 5 hours before RP was notified R1 was taken to Sutter Hospital for treatment and died on 1/10/2023.

The Department requested and reviewed R1’s physician’s report and assessments. R1 was admitted to Sterling Court at Roseville on 6/27/2022. R1’s physician’s report was completed on 6/25/2022. According to R1’s physician’s report, R1 can manage own treatment, medication, and equipment. R1 has visual impairment and wears glasses. R1 is not confused/disorients, does not have wandering behaviors, is able to follow instructions, able to communicate needs, and is not able to leave the facility unassisted. R1 is not able to bathe self and dress/groom self, and care for own toileting needs. R1 is ambulatory. R1’s assessment was completed on 10/20/2022. According to R1’s assessment, staff assists R1 with oral care, dressing and grooming, skin care needs, and bathing. No falls or risk factors noted.

The facility submitted all communication with R1’s primary care physician (PCP) for review. On 8/9/2022, the facility sent a fax to R1’s PCP indicating, R1 had a fall from R1’s bed this morning when trying to transfer themselves. R1 has small abrasions/tear to upper of right arm, and some redness to right knee. Wound cleaned and bandages applied. Staff will continue to watch and remind R1 to call for assistance. On 1/2/2023, the facility sent a fax to R1’s PCP to notify them of R1’s fall. R1 was sent out to Sutter.

The facility submitted an unusual incident/injury report to the Department for review. According to the incident report, on 1/2/2023 at approximately 12:40 a.m., Med Tech heard someone yelling for help. Med Tech went to R1’s room and found R1 on the floor near R1’s bedside. R1 stated R1 fell and had bruised R1’s elbow, skin tear on right bicep, and was in pain. R1 was transported immediately to Sutter Roseville ER for evaluation. R1’s RP and PCP was notified via fax.

The Department requested for R1’s medical records for review. According to R1’s medical records, R1 was arrived at the facility on 1/2/2023 at 1:27 a.m. R1 was diagnosed with Acute Traumatic Subdural, closed fracture of sacrum, and severe protein calorie malnutrition. R1 had medical history of COPD, HTN, nausea and vomiting, Osteoarthritis, and total hip replacement. Per Sacramento Vital Records Office, R1 passed away on 1/10/2023. R1’s cause of death was, Acute Traumatic Subdural Hematoma. Secondary causes of death were, Closed Fracture of Sacrum, Unwitnessed Fall, Chronic Obstructive Pulmonary Disease.

R1 made complaints of a “transition piece” between the carpet and the laminate floor by kitchen sink/ R1 complained R1 was tripping on the metal transition piece. Per staff the maintenance personal placed tape on the area to fix it. Maintenance staff was interviewed. Maintenance stated the metal transition piece was removed, adhesive was placed in the slit between the carpet and laminate, the metal piece was placed back in the slit and tape was placed over the metal piece to ensure the glue adhered. There is no proof R1 ever actually tripped over the transition piece. The night of R1’s fall on 1/2/2023, R1 was found lying on the floor, beside R1’s bed. Although R1 did sustained four falls while living at the facility, R1 was not a fall risk. Due to R1 not being a fall risk, R1’s care plan was not updated to implement any sort of fall mitigation. R1’s last fall per R1’s death certificate did contribute to R1’s death; however, the facility followed R1’s care plan and care needs. The fall was unwitnessed and once R1 was found, the staff took appropriate measures to seek medical attention.

Allegation: Staff did not notify residents authorized representative of incident in a timely manner. – Unsubstantiated.

Interview statement received from R1’s RP indicated, on 1/2/2023 around 1:15 AM RP received a telephone call, but RP did not answer. The facility called back around 6:15 AM, to report R1 was sent to the hospital. RP stated R1 hit R1’s head and was placed in the Emergency Room for observation. Five hours before RP was called R1 was taken to Sutter Hospital Roseville for treatment and died on 1/10/2023. R1 was unable to recall the incident. RP tried to get answered from Executive Director (ED), Chad Rogers, but ED stated was leaving the facility and someone named “Pam” was going to take over and would be able to assist RP.

The facility submitted an unusual incident/injury report to the Department for review. According to the incident report, on 1/2/2023 at approximately 12:40 a.m., Med Tech heard someone yelling for help. Med Tech went to R1’s room and found R1 on the floor near R1’s bedside. R1 stated R1 fell and had bruised R1’s elbow, skin tear on right bicep, and was in pain. R1 was transported immediately to Sutter Roseville ER for evaluation. R1’s RP and PCP was notified via fax.

Allegation: Residents floor is in disrepair. – Unsubstantiated.

The Department conducted interviews with two (2) of R1’s responsible parties (RP). R1 indicated that R1 kept complaining of the transition piece in R1’s room. R1 told RP that R1 was tripping over this transition piece and the facility would not fix it. RP stated the facility placed a tape over the transition piece to fix it, nut R1 continued to trip on it. RP admitted RP never witnessed R1 trip over the transition piece. Interview statement received from R1’s RP2 indicated, R1 made complaints about R1’s floor being lifted and R1 was tripping over it. R1 asked staff to fix it and apparently the staff put tape over the lifted area to “fix it.”

The Department interviewed a total of eight (8) facility staff. Interview statement received from S1 indicated, R1 has made complaints to S1 regarding a transition piece in R1’s room. R1 complained about tripping over the transition piece. S1 never witnessed R1 trip over the transition piece and asked R1 if R1 reported the transition piece to management. R1 told S1 that the maintenance staff places a piece of tape over the transition piece. S1 never witnessed the transition piece “stick up” but noted R1’s shoes would get stuck on the transition piece, causing R1 to trip. Interview statement received from S3 indicated, S3 was aware of the complaints R1 made about the transition piece. S3 put in a repair order with maintenance and the transition piece was fixed. S3 never witnessed the repair. Interview statement received from S4 indicated, maintenance was notified about the transition piece, and they fixed the area. S4 recalled the maintenance placed tape over the transition area. Interview statement received from maintenance (S5) stated, if the transition piece is sticking up, the staff will remove the piece, place flue in the seam, and then place tape over the transition piece for three to four days to ensure the glue will hold properly. S5 stated S5 did not fix R1’s room. Interview statement received from S8 indicated, S8 did not observed blue or white tape on R1’s transition piece. S8 stated, if there was a blue tape or clear tape that was on the floor it would have caught S8’s attention.

On 3/14/2023, LPA Yang arrived at the facility unannounced to open complaint investigation. LPA Yang requested for relevant documents pertinent to the investigation. LPA Yang took three photographs of R1’s bedroom. LPA yang did not observe floor in disrepair.

Based on the Department’s investigation as stated above, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and report provided.