1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Regarding Allegation #1: this investigation revealed Resident #1's Unusual Incident/Injury Report (dated 12/13/20) was submitted to CCLD regarding Resident #1's diagnosis and receiving the treatment; however, when the facility received the results, Resident #1 had already moved out of the facility on 12/11/2020 by the Public Guardian. Resident #2's Unusual Incident/Injury Report was submitted to CCLD on 12/15/20 regarding an incident that occurred on 12/11/20 regarding personal rights. Based on reporting incidents, the facility documented and made the appropriate notifications to Resident #1 and #2 authorized representative.
Based on evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation of REPORTING REQUIREMENTS: Staff do not report incidents to Authorized Representative is found to be UNSUBSTANTIATED.
Regarding Allegation #2: this investigation revealed that Resident #1's functional capabilities (based on a Record Assessment, dated 01/28/19), the resident does not use a brace or crutch or walker, but uses a wheelchair and can get in and out unassisted. A review of the "Physician's Report" (dated 01/17/19), documented Resident #2 is ambulatory and under "Physical Health Status" the resident does not require assistive device and is in fair condition. A review of the "Facility Progress Notes" (from 05/14/20 to 09/08/20) documented the resident's last known fall at the facility on 05/14/20 at 2:10 p.m. Resident #1 had become more anxious and agitated in the evenings and fell out of bed and out of the recliner chair. Based on interviews conducted of facility staff, the majority indicated that Resident #1 had a home health (Care More) nurse practioner that would visit the resident once a week. Facility staff had not witnessed Resident #1 to be found on the floor covered in feces during their shift rounds. Resident #1 would slide out of its bed or the recliner; however, there had not been reported falls up until the time that Resident #1 moved on 12/11/20.
Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF CARE: Resident has had multiple falls is found to be UNSUBSTANTIATED.
An exit interview has been conducted and a copy of the Complaint Report was provided to the Administrator, Laura Hernandez.
|