complaint·January 14, 2025

Staff did not ensure medical attention was provided to resident in a timely manner. On the allegation that the staff did not ensure medical attention was provided to resident in a timely manner; it is the concern of the reporting party (RP) that R1 sustained an un-witnessed fall, and after the staff (S1) discovered R1 on the floor, S1 failed to provide immediate assistance to R1 and did not call 911 until five (5) hours after R1 was discovered on the floor. The interview with S1 revealed that after S1 discovered R1 on the floor, S1 attempted to assist R1 to get up, but R1 did not want to be touched, and mumbled something. S1 did not notice any injuries, and R1 was not complaining of pain. Furthermore, S1 stated that they called R1’s POA before calling 911 and asked the POA if they wanted S1 to wait on calling 911 until the POA arrived at the facility, and the POA stated, “Yes”. The interview with the administrator revealed that after being informed by S1 that R1 had sustained a fall, they told S1 that they should have called 911 to provide medical assistance to R1 right away, then S1 should have called the POA and the administrator. The LPA interviewed the POA on 01/07/2025, and the interview revealed that on 12/27/2024, the POA received a call from the facility and was informed at approximately 10:00 a.m. of the fall sustained by R1. The POA stated that after S1 explained the incident, S1 asked the POA if S1 should wait until the POA arrived before calling 911, and the POA stated, “yes to wait”. The POA arrived at the facility and saw R1 laying on the floor. The POA noticed bruising on the left side of the forehead, shoulder and wrist. Emergency medical team (EMT) personnel arrived at the facility and found R1 lying face down on the ground. When asked what happened, R1 stated that they slid out of bed, onto the floor earlier in the morning, and R1 reported bilateral leg pain. EMT noticed that R1 had visible bruising to the left shoulder and mild swelling to the left side of the face. Based on the information received through interviews, the facility staff did not ensure medical attention was provided to R1 in a timely manner. S1 waited approximately four (4) hours, before calling 911, and getting medical assistance to R1. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency was cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.