Complaint·November 2, 2022

LPA interviewed staff #2(S2) to obtain additional details on the call light monitoring system. According to S2, the front desk has a monitor that shows residents who called for assistance and the time they pressed their call pendant. When a call is not being answered after 15 minutes, the system would provide a signal which triggered the receptionist to call the caregiver(s) to answer that call. However, currently the night shift is not being monitored as the facility used to have a receptionist 24 hours a day but recently the pm shift staff left and the night shift staff took over that position which left an open position on the night shift, Therefore, there is no receptionist monitoring the call light response time on the night shift. Based on staff documentation of the fall, on 7/14/22, R1 had an witnessed fall at 3:10am and according to R1, that was the time when staff responded to R1's call pendant but the fall happened at 1am. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Report was discussed with Administrator, and Appeal Rights provided. Based on documents provided, staff noted that R1 sustained some injuries on R1's left hand due to the fall. Although staff did not document that R1 did not want to go to the hospital after the fall, however, R1 reported to LPA during the interview that staff offered to call an ambulance but R1 declined it. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is discussed with the administrator. A copy is provided.