Follow-up on corrections·October 21, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection and met with Magda Luis, Administrator. LPA stated the reason for today's inspection relates to resident (R1) who had an unwitnessed fall on 8/28/24, in the morning, and was sent out for emergency medical services later that day. The facility submitted an incident report to the Department on 8/30/24. The report for the emergency ambulance provider notes the facility contacted them on 8/28/24 (19:28 hours) for a fall, they arrived at the facility at 19:48 hours, and observed the resident to be resting in her bed. The report further states that resident had a fall earlier that morning (around 8:00 am), and had been sitting in a chair all day, as staff was unable to get resident to stand, contrary to resident's normal baseline of regularly walking around the facility. The report also states that facility staff reported to the ambulance provider they were told by morning staff that resident had a witnessed fall, did not hit her head, but were not given any additional details. Documentation reviewed shows resident arrived at the Emergency Room at 20:16, was diagnosed with a fractured left hip and remained hospitalized until 8/31/24 when she was discharged to skilled nursing for rehabilitation. Several staff interviews were conducted, concluding resident (R1) had fallen and was found on the ground in the courtyard, on 8/28/24, after breakfast and before lunch was served, between approximately 10:00 - 11:00 hours. Staff interviews confirmed that after resident had fallen, (R1) was given assistance to stand up and was brought inside and seated in the dining room. Interviews revealed (R1) remained seated in the dining room until around 17:30 hours, when the facility nurse arrived to perform skin check on multiple residents. When the nurse observed (R1), she didn't want to stand up and complained of pain in her leg area. The nurse was advised resident fell earlier in the day and determined (R1) likely had a fractured hip, instructing that resident be sent out for a further medical evaluation. **cont on 809C-1.. 809C-1.. A "pm" staff stated he was made aware of resident experiencing pain around 17:00 hours, on 8/28/24, and stated if (R1) had been moving around during the "pm" shift, staff would have noticed her walking with difficulty. Additionally, staff interviews provided conflicting accounts if resident ate her lunch and dinner on 8/28/24, while seated in the dining room. The incident report (R1) notes resident around on 8/28/24, around 11:30 am-12:00 pm, and was sent out to the hospital for a possible injury. The family member reported to the facility that resident had a hip fracture and had surgery on 8/29/24. Based on information obtained, the facility did not ensure resident received timely medical attention following her fall on the morning of 8/28/24, as the ambulance provider was not called until 19:28 hours. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued. 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. Exit interview. Copy of report and appeal rights provided.