complaint·October 25, 2024

The investigation revealed the following: Regarding allegation: Staff did not seek medical attention for resident in a timely manner. It is alleged R1 waited 20 minutes before paramedics arrived. On 8/1/24, while getting into the facility’s van to go on an outing, R1 injured the knee while lifting self into the van. Due to this incident R1 needed medical attention to be requested. Interviews conducted with residents revealed they have received medical assistance in a timely manner or are certain that they will get assistance with obtaining medical care in a timely manner. Interviews with staff revealed staff was with R1 during the incident. R1 stated to be hurt and Wellness coordinator attempted to assess R1 but R1 did not wanted to be touch. Staff brought a chair to have R1 seat while waiting for paramedics. However, R1 refused. Per staff paramedics were called right away and arrived within 15 minutes of the incident. At the time of the incident there were two residents that witnessed the incident. The residents stated R1 waited less than 15 minutes and no more than 30 minutes. Document review revealed, an incident report dated: 8/6/24 notes that on 8/1/24 R1 “was not able to bare weight on leg while getting into facility’s van” at approximately around 11:30am and 911 was called by staff. Pasadena’s Fire Department service log notes the service call was received at 12:29pm. Fire department responded and service with transport to the hospital within 15 minutes of the call. Per documents review facility staff had a delay of an hour to obtain emergency services/medical attention for R1, who sustained a fracture while getting into the facility’s van. Therefore, the allegation is substantiated. Based on LPAs interviews which were conducted and records review, 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 LIC 9099D. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff did not ensure facility van was accessible for residents to get in. It is alleged R1 couldn’t get into the van due to it not having any steps to use to climb into, and instead using a kitchen stool to get into the van. Interviews conducted with residents revealed the facility uses a step to assist residents into the van's step. However, residents on wheelchairs or walkers are assisted into the van through the wheelchair lift. Residents that witness the incident stated the step was placed in the cement and had no issues getting into the van while using it. Interviews with staff revealed the step is a commercial stepping stool which is used to assist the residents get into the van. Driver present at the time of the incident stated to have place the stool in the pavement next to the facility’s van step, across from the curve of the sidewalk. Driver stated to have offer to use the lift to assist R1. However, R1 had chosen to use the step to get into the van. On 9/26/24 LPA observed facility’s van. The following observations of the van were noted, the van is in good repair, with a build-in step inside the van by the side door. Step is in good repair. The van has a wheelchair lift in the back, also in good repair. Stepping stool is a commercial grade step which measures approximately 16 in. by 12 in. Although R1 was injured while stepping on the stepping stool, the facility provided the stepping stool as additional support for the residents, the van and step were in good repair, stepping stool was placed in a flat surface when the incident occurred. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.