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The following reflects the findings of the California Department of Public Health - Licensing and Certification during a Complaint Validation Survey conducted on 12/15/10.

Complaint Number: CA 00245748

Representing the California Department of Public Health - Licensing and Certification: Diana Naveria RN HFEN.

The inspection was limited to the specific area of complaint and does not represent the findings of a full inspection of the facility.

ONE DEFICIENCY was issued for Complaint CA 00245748.









Based on staff and family interviews, clinical record and Administrative document reviews, the facility failed to assure patient safety when Sitter (person assigned to constantly observe, protect and prevent a patient from potential injury due to personal activities and the inability to identify hazardous conditions) failed to notify the nursing staff of personal needs, and left the Patient unattended, resulting in injury from a fall.

On 12/15/10 at 11:32 a.m., during a telephone interview, D 1 indicated that a Sitter assigned to her Mother had left her unattended and in the Sitter's absence, her Mother fell and had landed on her face.

On 12/15/10 at 2:30 p.m., during an interview the Risk Manager (RM) stated, "...Patient had a 1:1 Sitter from a private company...she left the Patient room to use the bathroom and did not inform...facility staff...patient fell while she was gone."

On 12/15/10 at 3:30 p.m., during a clinical record review of the MD Progress note, dated 8/27/10,, the note indicated..." patient fell today ( 1:1 (one person to one patient) Sitter went to BR (bathroom)."

On 4/28/11 during review of the facilities current policy and procedure, "Sitter/Close Monitoring of Patients" dated 9/22/08, indicated, "III. Staff Expectations for Sitter/Close Monitoring Patient Care, D. Staff will be relieved for breaks by another appropriate staff person prior to leaving the patient(s)."