complaint·September 21, 2022

(Continuation from Page 1) Fall incident was reported to hospice agency. R1 was evaluated by hospice nurse. X ray was requested and revealed “slightly displaced impacted subcapital fracture is noted Degenerative Joint Disease (DJD) is present and osteoporosis suggested. Right hip fracture”. R1 remained in the facility and managed with maximum assistance and medication. The Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation that resident sustained severe fracture while in care is deemed UNSUBSTANTIATED. On allegation that staff did not seek medical attention in a timely manner, the following are the findings. The first fall incident for R1 occurred around 2:00 AM of April 20, 2022. R2 observed R1 got out of bed and began walking unsteadily before the fall. Staff rushed towards the room and observed R1 on the floor. Staff checked R1 and did not observe apparent injuries. R1 stated no pain and responded to questions well. Staff was assisting R1 to get to showers when R1 reported pain. Staff called hospice agency for evaluation. Around 9:00 AM, when hospice nurse arrived in the facility and evaluated R1. After the initial medical assessment was made, R1 remained in the facility and managed with pain medications. Thus, the allegation that staff did not seek medical attention in a timely manner is UNSUBSTANTIATED. On allegation that staff did not notify authorized representative of the incident, the following are the findings. Per interviews, Responsible Party (RP) for R1 confirmed that RP received a report from Administrator (AD) Juan Reyes regarding the fall incident. Staff attempted to contact another authorized representative using the contact information available. Thus, the allegation that staff did not notify authorized representative of the incident is deemed UNSUBSTANTIATED. LPA Marin conducted an exit interview with AD Juan Reyes. Copies of this report were left in the facility.