complaint·December 3, 2024

evaluation followed the incident. Based on an interview with S1, the caregiver involved, S1 confirmed awareness of the fall policy during their interview but did not act in accordance with it. Based on documentation reviewed, it showed that R1 was identified as a high fall risk. R1’s care plan, a joint agreement between R1’s family and the facility, included the consistent use of a bed alarm to prevent unassisted movement that could lead to falls. S2 confirmed activating the alarm before their shift ended at 9:30 PM. However, at 11:30 PM, S1 found R1 on the floor with no alarm sounding, suggesting the alarm was either turned off or malfunctioning at the time of the fall. Failure to ensure the alarm was functioning compromised R1’s safety, as it prevented prompt staff response. Based on records reviewed, the facility protocol for unwitnessed falls and need for immediate notification. Care Plan Documentation: Care plan agreement between R1’s family and facility specified the use of alarms to mitigate R1’s fall risk. On June 1, 2024, at approximately 11:30 PM, R1 was found on the floor by S1, who assisted R1 back into bed without a medical evaluation or consultation with any staff members. S1 failed to report the incident as a fall due to personal judgment. On June 2, 2024, at approximately 6:30 AM, staff observed R1 exhibiting signs of pain during their morning routine and transfers. By 3:30 PM, after a noticeable decline in R1’s condition—symptoms including swelling of the left hip, pale skin, increased confusion, and a skin tear on the left elbow—R1 was transported to the hospital. R1 was sent to the hospital nine hours after pain was first reported. Medical evaluation at the hospital revealed a displaced comminuted basicervical femoral neck fracture and osteoarthritis of the hip. R1 passed away on June 16, 2024, with the primary cause of death identified as the femoral neck fracture and fall. Any report of pain following a potential fall should prompt immediate evaluation by Med-Tech staff, but R1 did not receive this evaluation. Staff interviews confirmed that R1’s condition worsened throughout the day, and only then was hospitalization sought. Based on records reviewed, R1’s fall (6/1/2024) to hospitalization (6/2/2024) document a gap in medical response. Medical Reports: X-rays from the hospital confirmed R1’s femoral neck fracture. Interviews: Staff accounts confirm R1 reported pain throughout the morning without escalation to Med-Tech or administration. Death Certificate: Cause of death includes factors directly related to the fall and delay in medical care. Facility Policy per administrator notes the facility policy mandates that any unwitnessed fall requires immediate medical assessment, which S1 did not pursue. The facility’s failure to properly train and instruct staff on reporting and responding to falls contributed to a delay in essential medical care for R1. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued. Appeal rights provided, exit interview conducted. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.