complaint·October 28, 2024

In an interview, Cortez said that, since R1 had hit their head when falling, staff were required to call 911. Cortez said that after the initial visit from paramedics, R1’s responsible party (F1) was called to request that F1 take R1 to the hospital. Cortez explained that she was concerned that R1 could have suffered externally unidentifiable brain trauma, and wanted R1 to be seen by a doctor. Cortez said that R1 continued to seem off baseline, which necessitated a second call to first responders. According to Cortez, F1, who is an attorney-in-fact for R1, said staff could call first responders a second time and take R1 to the hospital. Paramedics responding to this second call said that R1 was able to refuse to be taken to the hospital, and so did not take R1, according to Cortez. Cortez said F1 was contacted again, and after further discussing the situation, F1 agreed to have F2 take R1 to the hospital. Cortez said that she was clear while speaking with R1’s responsible party that R1 was not being forced to go to the hospital. In an interview, F1 said that she was told by Cortez over the phone that part of the facility’s admission agreement indicated that R1 had to be sent out to the hospital because R1 hit their head when they fell. F1 said they did eventually agree to have R1 taken by emergency services to the hospital, and after the paramedics declined to take R1, they further agreed to have F2 take R1 to the hospital. F1 said that, before R1 was even seen at the hospital, Cortez called F1 back and said R1 did not need to be seen at the hospital per facility policy. F1 said R1 was not admitted to the hospital. LPA Moleski reviewed this facility’s admission policies regarding emergency medical services and observed no such provisions requiring residents to be seen at a hospital following a fall in which they suffer a blow to the head. LPA Moleski reviewed Commons policy regarding falls which states that caregivers or other staff will call emergency medical services when a resident “exhibits any change in level of consciousness, or received obvious head … trauma.” LPA Moleski did not review any additional policy documents which describe the frequency with which 911 shall be called in the event of a resident fall. 22 CCR Section 87465(g) states that licensees “shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health….” Additionally, 22 CCR Section 87466 states that licensees shall “ensure residents are regularly observed for changes in physical … functioning and that appropriate assistance is provided when such observation reveals unmet needs … When such changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible party….” [continued on 9099-C] In an interview, R1 said they did not feel forced to go to the hospital, but said staff provided a “strong suggestion” that they should be seen by a doctor. R1 said the outcome of the discussion with staff and paramedics was that R1 could refuse to be sent out if they did not want to be sent out. In interviews, two staff present during the incident as described above on 9/6/2024 (S2-S3) said they did not observe other staff members forcing or pressuring R1 to be seen at the hospital. The department has determined the following as it relates to the allegation that staff pressured a resident to accept emergency transport to the hospital: Based on interviews and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Cortez.