Complaint·November 9, 2021

During the course of this investigation, Investigator Patterson conducted interviews with R1's FM and Licensee Krystal Adams. The investigation revealed the following: Regarding allegation of Staff did not seek timely medical attention for resident who sustained a fracture to hip requiring surgery . Investigator Patterson interviewed R1's FM who stated that on 1/15/20 they received a call from the facility licensee/ administrator, Krystal Adams, who reported to them that R1 had sustained an unwitnessed fall on 1/14/20 that went unreported by S1-2. R1's FM reported to Investigator Patterson that they were also informed that S1-2 assisted R1 back into bed after the unwitnessed fall. R1's FM stated that R1 did not receive timely medical care after the fall and was not assessed until 1/16/20 at which time GL Hospice came to the facility to take a portable x-ray of R1. X-Rays showed that R1 sustained a hip fracture and required surgery. R1 was taken off of hospice care on 1/17/20 due to the need for surgery and was transported via private ambulance, which was paid by the facility, to UCLA Santa Monica and had hip surgery on 1/18/20. R1 did not return to the facility after their discharge from the hospital and was placed in a Skilled Nursing Facility. Investigator Patterson also interviewed Licensee/ Administrator Krystal Adams, who confirmed that R1 fell on 1/14/20 and that S1 and S2 both failed to report the fall to licensee/ administrator. Licensee Adams stated that she found out about the fall/ injury until nearly 24 hours after the incident when another facility staff (S3) called her to notify her and asked her to come to the facility to assess R1. Mrs. Adams stated that she arrived at the facility late in day on 1/15/20 and she assessed R1 and being a medical professional (Nurse Practitioner) she noticed immediately that one of R1's legs looked shorter than the other and required medical attention, at which time she contacted R1's family members and GL Hospice. Licensee also stated that R1 did not receive medical attention until 1/16/20 when a Registered Nurse from GL Hospice visited R1 and took X-Rays which confirmed that R1 sustained a hip fracture and required surgery. Licensee stated that she informed R1's family about R1's need for surgery at which time the family struggled to decide on whether to call 911 or to use private transportation due to hospital preferences. Licensee stated that R1 was transported to UCLA Santa Monica via private ambulance paid for by the facility. R1 was admitted to the hospital on 1/17/20 and had hip surgery on 1/18/20. Licensee stated that R1 did not return to the facility. Based on interviews 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, Tittle 22, Division 6 and Chapter 8 are being cited. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to Staff did not seek timely medical attention for resident who sustained a fracture to hip requiring surgery . At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(B)(i) and may be assessed at a later date. Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421M (Civil Penalty Assessment), and Appeal Rights were provided to Licensee Krystal Adams.