complaint·April 15, 2025

At the time of being admitted, hospital records report R1 was unable to move or walk. Upon being admitted, R1 was diagnosed with a pelvic fracture. Based on interview, a facility staff (S1) stated on 7/17/23, R1 informed S1 that they had fallen in their bedroom after lunch but denied experiencing any pain or discomfort. S1 did not observe bruises or swelling on R1; however, R1 appeared to be in pain at the hip prompting S1 to persuade R1 to go to the hospital. S1 did not contact 911, as the situation was not considered an emergency or life-threatening. Instead, S1 called area hospitals, and Los Angeles Community Hospital was the only nearby hospital with medical transport vehicles available. An ambulance arrived and transported R1 to the hospital. R1’s Power of Attorney (POA) was notified prior to the transport. When interviewed, R1 could not recall how they fell but stated they felt safe at the facility. R1’s Power of Attorney (POA) reported last seeing R1 on July 15, 2023, at which time R1 appeared to ambulate fine and did not complain of any pain or discomfort. Per facility needs and assessment plan dated May 26, 2023, R1 uses a walker when ambulatory and has no limitations when transferring to bed. Although R1 sustained an unwitnessed fall and staff did not immediately call 9-1-1, R1 was able to communicate their pain level to staff and did not present in dire need to be medically evaluated. Based on R1’s assessment, R1 was alert and able to accurately communicate their needs. Therefore, based on interviews conducted and documents reviewed, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Song, and a copy of this report and confidential names list was left at the facility.