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32 | (Continuation from LIC9099)
R1’s responsible person reports that if staff were properly supervising R1, R1 would never have fallen. R1’s responsible person reports that R1 does not need a one-on-one caregiver but believes that if staff were providing adequate supervision the fall could have been prevented. LPA requested and collected a copy of an incident report for the fall R1 experience on 5/27/2026. An incident report dated 5/27/2026 details that at 10:39AM, R1 was in the dining area, standing, and holding a chair when she fell back. An interview conducted with Staff #1(S1) reports that they were in the dining room ending an activity with the residents and began loading the activity cart. (S1) reports hearing a loud thump and immediately rushed towards the noise. S1 reports observing R1 lying on their back. S1 reportedly placed their hand under R1’s head to provide support. As S1 was providing support, S1 recalls feeling a lump forming on the back of R1’s head. Interviews with Staff #2 (S2) reports that they were assisting Staff #3 (S3) with the facility’s care track app while occasionally glancing back at the resident. S2 reports hearing a loud thud; S2 rushed towards R1 after observing R1 lying flat on their back. Interview with Staff #4 (S4) reports that they were in the Business Office when they heard a loud thump. S4 stated that they rushed out of the Business Office and into the dining room where R1 was observed lying flat on their back. Interviews with S2 and S4 confirmed that R1 sustained a lump on the back of the head, and no additional injuries were observed. LPA attempted to interview R1 but due to R1’s cognitive abilities, the interview attempt was unsuccessful. LPA attempted to conduct an interview with Staff #3 (S3) but S3 did not have a great recollection of the incident occurring on 5/27/2026. LPA Flores obtained a (22) twenty-two second clipped video footage of the incident. LPA observed R1 standing in the dining room, holding onto the back support of a chair. S1, S2, and S3 were observed holding onto a cellphone facing the opposite direction of R1. R1 was observed suddenly falling backwards pulling the chair onto the ground. S1 and S2 were observed immediately responding to the fall by rushing towards R1 then followed S3 and S4 just seconds after. The clipped video ended once staff approached R1.
Therefore, the allegation of resident sustained an injury due to staff neglect or physical abuse is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means 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 allegations are unsubstantiated at this time.
An exit interview was conducted, and a copy of this report was provided to Business Office Manager Nicole Anguiano. |