Complaint·March 22, 2022

The second incident occurred on 07/14/21. Facility’s documentation indicated on 07/14/21 at approximately 5:00pm, R1 was observed by staff to be very restless, agitated, and unable to redirect. R1 was also observed by staff leaning towards their right side and unstable while walking; R1 required staff assistance while walking to prevent R1 from falling. On 07/15/21 at 12:44pm the facility contacted R1’s Psychiatrist for direction. The Psychiatrist’s nurse responded at 1:03pm, and recommended contacting R1’s Primary Care Physician (PCP). The facility did not contact the PCP until instructed by the Psychiatrist’s nurse. On 07/15/21, the facility contacted the PCP at approximately 1:03pm but did not receive a return call until 1:48pm. The PCP advised staff to send R1 to the hospital for evaluation. Staff interviews revealed R1’s vitals were taken and there was no urgency to send R1 out for evaluation. Facility’s documentation indicated R1 required medical attention on 07/14/21 when R1 was observed leaning towards the right side and unable to walk unassisted. Facility’s documentation indicated on 07/15/21 at approximately 1:51pm, facility staff activated 911. R1 did not receive medical attention until 07/15/21 at 2:20pm, which was arrival to the hospital. On 07/15/21, R1 was transported to the hospital via 911, not non-emergency ambulance services, which demonstrated immediate medical attention was needed. At the hospital, R1 was diagnosed with a medical condition and prescribed a new medication. Emergency Department Physician Notes reflected the chief complaint was for right sided weakness and stated, "facility thinks it was around 5:00pm on 07/14/21, does have a facial droop". It also stated R1 had “been leaning to the right when sitting, staff were concerned for mild right facial droop. The symptoms are close to 24 hours since onset.” Facility staff were aware R1 had right sided weakness and unable to walk without assistance but did not send R1 out for evaluation. R1 didn’t receive timely medical treatment until approximately 21 hours after observation of weakness and leaning to their right side, along with facial droop. Based on documentation and interviews, which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The facility did not seek timely medical treatment for R1. R1 was not evaluated until approximately 21 hours after observation of weakness and leaning to their right side. California code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099D. [See LIC 811 Confidential Names List to identify Resident #1]. An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents. Staff indicated they are busy providing care to the residents and are unable to answer the phone each time it rings. However, staff are required to check the voicemail's by the end of their shift and return all voicemail's. Further outside source interviews revealed in 2021, there were some issues with not receiving returned calls, but it was unknown if it was due to lack of staffing. Additional interviews revealed once the facility was aware of the issue, it was rectified, and the facility provided the facility’s nurse’s contact information to families/friends as a resource. A review of the facility’s staffing schedule for July 2021 revealed the facility had sufficient staffing to answer the phones. The facility’s staffing schedule reflected caregivers and medication technicians on all shifts. Staff interviews revealed in addition to the schedule, the facility also had an LVN for the AM/PM shift, lunch, and throughout the NOC shift; and the memory care unit Director who is also an LVN worked 5 days a week and was on call 24/7. Based on interviews, which were conducted and record review, we have found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred and is therefore determined to be unsubstantiated. An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.