Complaint·April 29, 2022

A copy of a fax cover sheet from the facility to R1's doctor confirms that family members of R1 called 911 to assist R1 from an unwitnessed fall. I nterviews and facility records confirm that one of the staff members (S1) who generally has possession of one of the two "after-hours" phone lines was on a FaceTime call with another resident's doctor (and therefore unable to answer the telephone) during the time that 911 responded to the facility to assist R1. Staff are unclear on why the other after-hours phone was not answered. The facility's pendant alert call records show that on 4/24/22 at 5:41pm, R1 pressed their pendant for assistance. The same records show that a staff member (S2) acknowledge the call over one hour later, but the call was not cleared for over 11 hours. Facility staff charting notes that 911 responded to the facility at approximately 6:35pm, which is almost one hour after R1 initially pressed their call button, and approximately one half hour before the pendant alert logs show that staff even acknowledged the alert on their devices. When LPA Colvin interviewed the Assistant Executive Director (AED) requesting their opinion on how long is an appropriate amount of time for a resident to wait for assistance, the AED declined to provide a specific time frame. LPA Colvin asked the same question of another staff in a leadership position, and was answered with "5 to 8 minutes" or to have staff at least "pop in to see what is needed if they know they are going to take longer". In either case, it is clear that this was not followed as R1 pressed their pendant for assistance at 5:41pm, and was not provided with assistance until 911 responded nearly an hour after R1 initially requested staff help through pressing their call button. Therefore, based on interviews and record review, the allegation " Staff did not assist resident from fall in a timely manner." is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Assistant Executive Director Lorena Vivar during the exit interview.