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Through interview LPA ascertained that the facility allows ambulatory residents to sit in the rear seats while non-ambulatory residents sit at the seats directly next to the van’s side doors. Resident R1’s LIC 602A Physician’s Report lists R1 as being ambulatory. While exiting the van, resident R1 got their foot caught in the back of the seat next to the side door and hurt their knee. Staff member S1 who was accompanying/driving the residents immediately called the facility to report the incident and emergency services were notified. Facility ED Lua drove to the location where the incident occurred. Emergency services arrived on the scene and recommended that resident R1 be transported to the hospital for further examination. Emergency Services reported that their ambulance was already transporting someone to the hospital. Emergency services suggested that the facility transport R1 to the hospital for expediency. The facility then transported R1 to Providence Healdsburg hospital. Resident R1 was diagnosed with a minor knee injury that did not require any surgery or casting. Resident R1 returned to the facility later the same day. Resident R1 has had no further complications resulting from their injury on 5/26/2026. LPA examined the facility van and found no safety hazards. LPA reviewed staff member S1’s training file and observed that S1 has completed all required annual training including fall prevention. LPA could not find any evidence of a lack of supervision or of an unsafe environment for residents. So, 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 allegation is UNSUBSTANTIATED. |