Incident investigation·June 10, 2024

On 06/10/2024 LPA Jaynae Boyles and LPM Lauren Crocker held an office visit to meet with Licensee/Administrator, Kathrine Abejo to discuss concerns regarding an incident report received from the licensee. The report received on April 26, 2024 outlines an incident where a resident (R1) sustained a fall in the early morning hours on 4/24/24, followed by a detailed timeline showing the facility failed to seek medical attention in a timely manner. Details in the report include the following information: the fall happened at 4am on 4/24/24, followed by the resident being sent to day program by facility staff at 8:30 am. At 9:50 am that same morning, the day program sent the resident home stating R1 “is not feeling well” and “cant get up from her wheelchair to use the bathroom.” R1 was returned to the facility at 10:30 am. R1 had soiled their pants twice while at day program due to inability to transfer to the toilet. At 6:00 pm the same day facility staff contacted the facility Administrator, Kristine Abejo, to inform her R1’s left leg was swollen. According to the incident report, Abejo advised staff to put a leg brace on, which R1 used last year in March when R1 had a broken ankle, “until tomorrow morning because it hurts every time she moves.” The following day, 4/25/24 at 9:40 am, almost 29 hours after the incident occurred, R1 was taken to the medical clinic where they took x-rays. The doctor’s orders were for the resident to go to the emergency room due to x-rays showing that the tibia and fibula were fractured. At 1:00 pm at the emergency room and the administrator was informed that the resident “will need a surgery tomorrow by placing a titanium rod to straight the bone. She will stay at the hospital for 3-4 days.” As a result of the resident’s injury and the facility’s failure to seek medical attention in a timely manner, the violation warrants an immediate civil penalty in the amount of $500, which is being issued today. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49. Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Signature on this report acknowledges receipt of these reports.