complaint·September 18, 2023

Continued LIC9099-C page 2 Allegation: Facility staff did not follow reporting requirements. On 10/05/2022 R1 fell around 11:00 P.M., and did not receive staff assistance until the following day near breakfast time around 7:45 A.M., When staff brought up R1 breakfast that is when staff contacted the nurse and Med Tech to come and assist R1. R1 reported staff offered to send R1 to the hospital but R1 refused and decided not to go to the hospital. Staff was unable to prevent the fall from happening. Staff did not know of the fall until the next morning. R1 never called for assistance. The facility staff failed to report the special incident report to Community Care Licensing according to Title 22 Regulations on Reporting Requirements. Investigation revealed the following: On 11/07/2022, Interviews were conducted with staff 1-3 (S1-S3), and residents 1-8 (R2-R8), S1-S3 and R2-R8 stated staff provided the resident with immediate assistance. S1-S3 and R2-R8 stated residents never have to wait an extended period of time for assistance. S1-S3 stated the facility was unaware of the fall and the facility is fully staffed. Staff stated they had no control over the fall and could not have prevented the incident from happening. Staff did not report or submit a special incident report to the licensing agency or the person responsible for the resident within seven days of the occurrence regarding the incident Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D were provided to the Executive Director. Continued LIC9099-C page 2 During the tour, we tested R1's pendent and the room's call button, and both were found to be fully operational. S1 emphasized that the staff could not influence or prevent the fall incident, as they remained unaware of the event until the morning when the dining room staff visited R1's room to serve breakfast. R1 had not made any prior calls for assistance. Investigation revealed the following: During interviews conducted with Staff 1 to Staff 3 (S1-S3), it was established that they had no prior knowledge of Resident 1's (R1) fall on the evening of October 5th, 2022, at approximately 11:00 P.M. S1-S3 attested that R1 did not seek assistance nor did she report the incident at that time. It was emphasized that the facility maintains 24-hour care, with staff members consistently patrolling the premises. None of the staff reported hearing any indications or witnessing any movement associated with a fall during that particular timeframe. S1-S3 were unanimous in affirming that immediate assistance was promptly provided to R1 once they became aware of the incident, which occurred the following morning when staff was delivering breakfast at approximately 7:45 A.M. Upon being informed of R1's fall, staff promptly summoned the nurse and Med Tech to render aid. While staff offered to arrange for R1's transfer to a hospital, it was ultimately her decision to decline this option. Staff unequivocally asserted that they had no foreknowledge of the fall, as R1 did not contact them for assistance during the night. S2, a member of the staff, conveyed that she conducted a comprehensive body examination of R1 and found no evidence of bruises or injuries resulting from the fall. In R1's interview, she confirmed that on the date in question, October 5th, 2022, she had indeed experienced a fall within her room at approximately 11:00 P.M. However, she did not seek assistance at that time. Instead, it was during breakfast service at around 7:45 A.M. the following day that she brought the incident to the attention of staff, who promptly responded to her request for assistance. R1 reiterated that she did not make any prior attempts to contact staff for assistance. Residents 2 through 8 (R2-R8), when interviewed, expressed a unanimous sentiment regarding the accessibility of staff assistance. They affirmed that staff members are readily available to provide aid, and residents do not experience undue delays in receiving assistance. Additionally, R2-R8 conveyed their satisfaction with the level of care and supervision provided, highlighting the absence of any noteworthy issues, problems, or concerns in this regard. These residents expressed a sense of comfort and safety within the facility. Staff stated they had no control over the occurrence of the fall, rendering them incapable of preventing the incident from transpiring. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. There were no deficiencies cited. An exit interview was conducted.