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32 | amount of aid and supervision, including continence care and assistance with ADLs (Activities of Daily Living). C1 also exhibits self-injurious behavior on average once a month and disruptive behavior on average once a week. C1 is non-verbal. C1’s records also noted C1 had a diagnosis of osteoporosis and was at a high risk for fracture. C1 was admitted to the facility on 06/28/2018. A review of the Unusual Incident/Injury Report dated 11/08/2023 documents on 11/08/2023 at 12:15am two staff were changing C1’s adult brief and cleaning C1. Staff #1 (S1) moved C1’s right leg and heard a “pop” at C1’s right knee. C1 was noted as showing resistance during the incident. The facility nurse assessed C1’s knee and observed swelling and noticed C1 grimacing. C1 was given Tylenol and taken to the hospital. A distal femur fracture was diagnosed, and C1 was issued a splint. C1 then returned to Villa Verde Home facility. The staff involved were noted as S1, Staff #2 (S2) and the facility LVN. The facility’s actions taken was noted as “mandatory in-service and retraining on changing, showering, and lifting.”
The hospital medical records were reviewed. The records noted the emergency room (ER) visit on 11/08/2023 at 1:49am with a Chief Complaint of being brought in was staff was moving patient when they heard the right knee pop and patient appeared to be in pain. The notes indicate C1 is non-verbal at baseline and bedbound. The ER physician notes state the chronicity of the injury is unclear, but given C1’s bedbound status, it could be from a minor trauma although typically this is a higher mechanism injury. Later in the medical records, the X-rays and CT scans results noted the injury appears to be a “true accident.” A splint was applied and C1 was discharged back to the facility “safe to return home” the same day.
The Department’s investigation did not provide sufficient evidence and information to substantiate an allegation of physical abuse against Villa Verde Home staff pertaining to the fracture sustained by C1 on 11/08/2023. C1’s placement agency was also contacted, who confirmed the incident was reviewed by including interviews by a consulting Registered Nurse, as well as by another California Department Agency. No abuse or neglect was substantiated. C1’s primary physician was interviewed and the physician denied any concern for abuse or neglect, attributing the primary reason for the fracture was the medical fragility of the client. The Police Department also responded to the incident and declined to pursue the matter for any criminal violations. The information obtained during the Department’s investigation did not sufficiently support the allegation. While C1 did sustain a fracture, the investigation did not provide sufficient evidence to substantiate that physical abuse led to the injury. Therefore, the allegation is deemed Unsubstantiated at this time. A finding that the complaint 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(s) occurred. Exit interview conducted, copy of this report was reviewed and provided to Kaitlynn Buck. |