The investigation revealed the following:

Allegation #1: Resident sustained a fracture while in care.

This complaint alleged that resident sustained a fracture while in care from a fall. Resident #1 was admitted to Torrance Memorial Medical Center on 10/19/21 due to a fall observed (via) facility’s video recording. On 04/30/22, further review of R1’s medical records documented that the resident was experiencing health issues and x-rays done for the resident did not suggest any fracture was found. During the investigation, there were no reports of neglect or lack of supervision. On 01/10/23, LPA Calderon interviewed Administrator Martz. The administrator’s written statement (dated 11/01/2021) stated that Resident #1 sustained an unwitnessed fall based on the facility’s video recording. Administrator stated that R1 was sitting in a recliner chair, stood up, lost their balance, and fell to the floor. Staff #1 rushed to R1’s aid and assisted the resident off the living room floor. The Department’s Investigation Branch, Investigator Chrisine Ferris, found there was no evidence to corroborate the above-mentioned allegation. The information and evidence obtained did not sufficiently support the allegation.

This complaint alleged that resident sustained multiple falls while in care. Resident #1 did not have 1:1 care and reportedly did not have a significant history of falls. On 10/19/21, the caregivers on duty at the time of R1’s fall were preparing dinner within (approximately) 40 feet of where R1 was sitting prior to the fall. The facility’s video recording captured R1’s fall and the caregivers’ response time to be within an appropriate timeframe and providing the medical assistance including calling 9-1-1. Resident #1 was taken to Torrance Memorial Medical Center for a right fracture of the hip. Medical report does support a non-displaced fracture of the right femoral neck. A review of the hospital medical records on 04/30/22 does not support multiple falls while in care. On 01/10/23, LPA Calderon reviewed a written statement (dated 11/1/2021) from A1. The administrator stated that Resident #1 did not sustain multiple falls while in care; and that facility staff provided care to R1 after the fall happened on 10/19/21. On 10/29/22, LPA Calderon reviewed the video recording which suggested that R1 was in recliner chair, stood up, lost their balance, and fell to the floor. The video suggested that Staff #1 assisted R1 within seconds of R1 falling from the recliner chair. On 05/22/23, LPA Calderon interviewed staff (S1-S3). Staff #1 stated that if a resident fell, all staff would aid the resident’s medical needs. Staff #2 stated that it is rare for a resident to fall; but, if this does happen, facility staff will provide medical aid including calling 9-1-1 or taking a resident to the hospital, if needed. 2 of staff interviewed by IB Investigator Ferris denied R1 sustaining multiple falls in care. IB investigator conducted a review of R1 file and did not observe any documentation that R1 sustained multiple falls while in care. The Department’s Investigation Branch, Investigator Chrisine Ferris, found there was no evidence to corroborate the above-mentioned allegation. The information and evidence obtained did not sufficiently support the allegation.

Allegation #4: Staff did not follow a resident needs and care plan.

This complaint alleged that staff did not follow a resident needs and care plan. On 10/29/22, LPA Calderon interviewed A1. A1 states that staff take care of residents’ needs. A1 states that prior to entering A1 facility all residents must have a needs and service plan. A1 states that all staff must review and follow all resident needs and service plan. A1 states that all staff reviewed R1 needs and Service plan while in their care. On 10/29/22, LPA Calderon reviewed R1 needs and service plan R1 needs, and service plan suggest R1 has balance issues and health issues. On 10/25/22, LPA Calderon received and reviewed the department’s Investigation Branch (IB) Investigator name report. The investigator’s report states: The investigator spoke to staff and all staff followed R1 needs and service plan for R1 care. On 05/22/23, LPA Calderon interviewed staff (S1-S3). 3 of 3 staff denied the allegation. S1 states that S1 is required to review all residents needs and service plan prior to providing care. S1 states that S1 cannot provide the best care possible without knowing what the medical needs for R1 are. S2 states that S2 reviews all medical reports to include the needs and service plan for each resident. S2 states that S2 provides great service by understanding what the medical issues are for each resident. S3 states that the needs and service plan is required reading for each resident. S3 states that S3 provides better care by understanding what each residents’ needs are. On 05/22/23, LPA Calderon attempted to interview residents (R2-R4) for complaint. Due to communication barriers residents could not answer any questions regarding the complaint. LPA conducted a review of R1 Care plan and did not note any discrepancies between the care staff stated they provide.

This complaint alleged that the facility has inadequate record keeping. On 10/29/22, LPA Calderon interviewed A1. A1 states that A1 staff keep adequate records on all care provided to residents in A1 care. A1 states that accurate records are kept for R1 to include all medical records and incident reports. A1 states that A1 staff are mandated to keep accurate records on all residents and that all resident’s family can obtain and review all records for their family member. On 10/29/2022 LPA Calderon reviewed the incident report (dated 10/19/2021). Incident Report stated that R1 was sitting in a recliner chair, lost their balance and fell to the floor. Staff called 9-1-1 and R1’s family to advise of the resident’s fall. On 10/29/22, LPA Calderon reviewed the facility’s video recording of R1’s fall. Facility took a video of the living room area. Video recording shows R1 sitting in a recliner chair. The video recording showed R1 trying to get out of their recliner chair, lost their balance, fell to the floor, and within seconds, facility staff came to R1’s aid. The administrator stated that A1 supplied a copy of video recording to R1’s family. The administrator stated that all facility staff follow and keep accurate records and staff take continuous training in record keeping. The administrator stated that all emails are kept and tracked for resident records. On 05/22/23, LPA Calderon interviewed staff (S1-S3). 3 of 3 staff denied the allegation. Staff #1 stated that they are trained to keep records for all resident’s care. Staff #2 stated that they are mandated to keep accurate records for each resident in S2’s care. Staff #33 states that A1 trains all staff to keep records of all care provided by staff to include any hospice records or hospital records. Staff #3 stated that these records can be reviewed by the resident’s family and the records must be accurate. On 05/22/23, LPA Calderon attempted to interview residents (R2-R4) for complaint. Due to health issues, R2-R4 could not answer questions regarding the complaint.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations: “resident sustained a fracture while in care” “resident sustained multiple falls while in care” “staff did not properly report an incident involving a resident” “staff did not follow a residents needs and care plan” “ facility has inadequate record keeping” are UNSUBSTANTIATED.

A face-to-face interview was conducted with Administrator Laura Martz and a hard copy of the Complaint Report was provided by hand for facility records.