complaint·October 1, 2024

Allegation: Staff left a resident unattended. It was reported that 95 year old resident fell in the bathroom on 7/17/2024 between the hours of 10PM -11PM, and laid on the floor for hours until morning the next day. A total of 7 staff were interviewed. The staff person that was in charge of R1's care during the NOC shift on 7/17/24 no longer works at the facility; therefore, was not interviewed. According to staff interviews, resident (R1) was found on the floor the next day (7/18/2024) at approximately 7:30 AM. The resident returned to the facility the same day of the fall, after completing rehabilitation orders following a hip replacement surgery in June 2024. Based on observation, resident rooms have pull string signal system in the resident's room and bathroom, and also provide a hanging or wrist pendant to residents. Resident (R1) was wearing the signal system wrist pendant at the time of the fall. However, the wrist pendant was inoperable. The resident was not able to reach the signal pull strings in the room due to injuries. Caregiver responsibilities include checking on residents every 2 hours, or 30 minute to 1-hour checks after resident's return from the hospital because residents may be weaker or have changes in condition. A total of 11 residents were interviewed, of which 5 residents stated that NOC shift staff sometimes take 45 minutes to 1 hour to respond to signal system. On 7/23/2024, LPA tested R1's signal wrist pendant and it was not operable. The findings reveal that R1 fell and none of R1's attempts to receive assistance were answered, and staff did not check on the resident between the hours of 10 PM - 7:30 AM. Based on record review, there is no documentation that R1 was being checked more frequently after returning from the hospital, nor whether the NOC shift caregiver (S8) was aware that the resident had returned from the hospital. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not ensure a resident's alert device was properly operating. It is alleged that R1 was not able to receive staff assistance or medical attention in a timely manner after falling in the room. The resident attempted for hours to call staff for assistance by pressing the bracelet/watch pendant, but it was not working. On 7/23/2024, LPA tested the wrist pendant and confirmed it was not operating. Staff interviewed stated the signal pull strings in resident rooms and bathrooms work, but stated that some residents had been provided wrist or hanging neck pendants for use. However, staff stated that they failed to check on wrist/neck pendants regularly, and were unaware that they were not operable. Resident interviews revealed, that not all residents were given or use wrist/neck pendants, but had heard residents complain to Administration staff that the wrist/neck pendants were not operating properly. During both visits, the signal system was tested. It was observed that the Memory Care Unit signal system is separate from the Assisted Living area of the facility. This facility does not have signal system pagers that alert staff on duty when a resident requires assistance. Based on observation, there is sufficient evidence to corroborate the allegation. Allegation: Staff did not properly report an incident involving a resident. It is alleged that resident (R1's) authorized representative was not notified of the fall incident that occurred on 7/17/24, and discovered the next day 7/18/24, at approximately 7:30 AM, until later in the day after a Kaiser Permanente Physical Therapist (PT) visited the resident and observed bruises in knees, arms, and upper body. The PT notified facility nurses to call R1's MD. Based on record review, staff completed a "Head-to Toe Assessment" at 11:30 AM. LPA reviewed facility charting notes, and there was no documentation of R1's fall or notification to physician or responsible party. The incident report obtained does not list the time responsible party or MD were contacted. Once facility staff notified R1's MD, it was recommended that R1 be transported to the emergency room for x-rays. A total of 11 residents were interviewed, all stated that facility staff notify their responsible parties. However, in this case R1's responsible party was not notified right after they addressed the resident's fall. The resident's family received a call from staff notifying them that MD advised for the resident to be evaluated at the emergency room, many hours later after the fall incident. Staff protocol is to call facility nurse after fall, then paramedics, and after the medical emergency has been taken care LVNs are to notify family. There is sufficient evidence to corroborate the allegation. Allegation: Staff overcharged a resident for services not received. It was reported that resident (R1's) authorized representative met with Administration staff the day (7/17/24) the resident returned to this facility after discharge from a rehabilitation facility. It was agreed that a new additional personal care rate in the amount of $550.00 would be charged for incontinence care, bathing assistance, escort assistance, and more frequent checks due to post surgery hospitalization, effective 7/17/2024. Staff stated that caregivers meet daily with LVNS to report changes in condition of the residents, but in this case when the resident returned to the facility they did not obtain discharge paperwork from the family. Administrator stated that staff began providing ADL assistance in April 2024 without charge when they observed decline, but family had not agreed to pay extra for the services. However, the findings indicate that family signed an Addendum to Rental Agreement for personal care the afternoon of 7/17/2024, with an understanding that R1 would be checked on more frequently than every 2 hours, because the resident returned from a higher level of care facility. Since, the resident fell the same day they returned to the facility and laid on the floor for hours, and after the authorized representative agreed to an increase in rate, there is sufficient evidence to corroborate the allegation. NOTE: Resident (R1's) authorized representative was refunded the pro rated personal care rate paid by the family. Allegation: Resident sustained unexplained injury while in care. It is alleged that resident (R1) sustained a hip dislocation i.e the hip replacement came out of the socket, when the resident fell on 7/17/2024. According to information obtained, the fall resulted in multiple bruising/scrapes in knees, arms, chest, and throughout R1's body. Staff acknowledged observing bruising on knees and arms, but the Head-to-Toe Assessment did not document bruising on the arm or hip bruising/redness. LPA obtained an x-ray photograph of the injury caused by the fall. It shows the the metal socket completely dislocated. The resident had to undergo another hip replacement surgery as a result of the major injury. The resident never returned to the facility after the 2nd hip replacement surgery and was discharged from the facility on 8/30/24. There is sufficient evidence to prove R1's injuries were a result of neglect of care. Based on interviews conducted, record review, and photographic evidence, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D. An exit interview was conducted. A copy of this report and appeal rights will be provided via email and mailed to facility Administrator Priscilla Gaytan because of printing issues.