complaint·May 16, 2024

Allegation: Facility signal system did not produce an auditory signal loud enough to summon staff. It is alleged Resident R1 was not feeling well in the middle of the night and pressed the medical alert button, but nobody came. R1 then called the front desk, and nobody answered the phone. During an interview with R1’s Responsible Party (W1) stated facility staff left them a voicemail stating the battery was low in R1’s pendant. Additionally, W1 stated when they brought R1 back from the hospital the following afternoon the facility’s phone system was still down. During interviews with Staff (S1 and S2), two (2) out of two (2) stated there was an issue with the phones on December 12, 2023, and that the phone system has gone down in the past. S1 stated there has been a new procedure implemented for when the phone system goes down and for the medical alert pendant to inform them when batteries are low on a resident’s pendant. During interviews with Residents (R1-R6) two (2) out of six (6) stated there has been times when they press their pendant for assistance and had to wait an extended period of time before a caregiver arrived and they received care. R6 stated there was a time they had to wait three (3) hours before assistance came. R1 stated that having to wait for assistance commonly occurs in the evenings and nights. During interviews with staff (S1-S7) seven (7) out of seven (7) stated they receive training annually regarding the medical alert pendants and had a training regarding the new procedures implemented regarding low batteries in pendants and the telephones when down. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Allegation: Lack of supervision. It is alleged that a resident fell in the night and waited for staff to help them till the morning when their breakfast was delivered. During interviews with Staff (S1-S7) seven (7) out of seven (7) stated rounds are to be done every two (2) hours per shift. Additionally, S2 stated if a resident is a fall risk or has recently returned from the hospital rounds are done hourly to check on that resident. During an interview with S3 stated there are some residents who prefer not to be checked on in the evenings. S3 marked the Resident Roster indicating which Residents do not want to be checked during the Noc shift. Upon review of that list, LPA observed R1 was not indicated on that list. During file review of Resident R1, LPA observed on the Physicians Report R1 needs medical supervision for fall precautions and on the Assessment Summary it is noted R1 has fallen in the past twelve months. During interviews with Residents (R1-R6), three (3) out of six (6) stated Staff come and check on them during the day. Additionally, during an interview Resident R1 stated staff comes and checks on them a limited number of times during the day. LPA asked R1 if they had any falls recently, R1 stated they had a fall, but they were doing much better. During an interview with R1’s Responsible Party (W1) stated R1 fell during the night, pressed their medical alert pendent at 4am, and called the front desk for assistance and could not get assistance. W1 stated R1 was able to pull themselves off the floor and waited until their breakfast was brought to them around 8:30am. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Deficiencies are cited on the attached LIC9099-D. An exit interview was conducted with Health and Wellness Director, Milca Osorio, and a copy of this report and appeal rights was provided.