complaint·February 16, 2023

R1’s Needs and Service plan developed by the facility dated 11/26/2021 stated that R1 requires redirection; However, does not specify if R1 requires a 1:1 caregiver. Based on interviews with staff during the time of the incident caregivers and staff were escorting other residents to breakfast. Staff present during the incident, reported they witnessed R1 walking the hallway and saying something to R2, before R2 then pushed R1. The witness stated they called over a second staff in order to assess R1. They then called over a third staff member in order to help lift R1 up. Staff interviewed reported R1 did not complain of any pain and was placed in a wheelchair. Based on interviews with 2 out of 4 staff indicate that R1 has been aggressive in the past, but this was monitored and treated with medication and redirection. R1 and R2 were unable to be interviewed as R1 passed away and R2 was not oriented to time and space during the interview. Per interviews with staff R2 was not aggressive and kept to themselves. Based on the preponderance of the evidence through review of documents and interviews the allegation resident pushing another resident causing an injury due to neglect is UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Based on interviews with staff and witness R1’s family called after the incident and was ask if they wanted to take R1 to urgent care. R1’s family came to the facility to pick up R1 and transported them to Hoag Urgent Care at approximately 11:30 AM, resulting in a three and a half hour delay in medical services. R1 was then transferred to the hospital where R1 was diagnosed with a fracture femur. The LIC 624 stated that the resident was transferred to the hospital after 911 was called. Per hospice paperwork, R1 returned back to facility on 04/24/2022 and was placed on continuous care from 04/24/2022 to 05/01/2022 before passing away. A civil penalty is pending determination, per H&S Code Section 1569.49(e). Based on the preponderance of evidence through record review and interviews the allegation staff did no seek timely medical attention for resident who fell is SUBSTANTIATED, meaning the complaint allegation as valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8 and civil penalties assessed An exit interview was conducted and a copy of this report and appeal rights was provided to the Executive Director.