Complaint·October 29, 2021

to the facility. Records indicate that R1 has hemiplegia, a paralysis on their left side of the body. Further evidence from facility records and interviews suggest that R1 is able to advocate for themselves, make their own decisions and able to communicate their needs. Evidence obtained from records and interviews revealed that R1 arrived back to the facility around 12:00PM; R1 reported to Staff 1 (S1) that they had a fall offsite, were in pain and requested to call an ambulance. S1 advised that they were instructed to get permission from the Administrator first before they could call for emergency medical services (EMS). Therefore, S1 called Administrator and left a voice message to report that R1 had a fall, was in pain, and requested for an ambulance. According to S1 and Administrator, they were aware that R1 was in pain but didn’t believe the pain was life threatening. Interviews conducted with Administrator revealed that they received the voice message from S1 around 1:00PM and it was when they discovered that R1 had a fall and sustained an injury. Around 1:40PM, R1 also contacted Administrator and left a message to report that they were in pain, however, Administrator did not receive the message until approximately 2:30PM. Subsequently, Administrator contacted R1’s family member to ask and determine which hospital to transport R1. Around 3:00PM, Administrator initiated EMS and around 3:20PM, R1 was transported to the hospital. Administrator acknowledged that there was a delay in requesting medical care due to awaiting a response from R1’s family member to which hospital to take R1. Evidence from medical records revealed that R1 sustained a left hip fracture from the fall. Evidence from the investigation revealed that licensee failed to proactively take the appropriate steps to ensure that R1 received medical care when they expressed pain and requested for an ambulance. This agency has investigated the aforementioned allegation. Based on evidence obtained from interviews, records review, and outside sources, allegation is deemed substantiated due to the preponderance of the evidence standard been met. A citation is being issued in accordance with California Code of Regulations, Title 22, and listed on the 9099D. An exit interview was conducted with the Administrator and a Plan of Correction was developed. A copy of this report and Appeal Rights (9058 01/16) were provided to the Administrator by electronic mail. A confirmation receipt was requested from the Administrator upon receipt of the documents. An exit interview was conducted, and Administrator was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.