complaint·February 15, 2024

Based on interviews conducted, it was learned that this incident was not reported to the responsible parties for R1 when R1 initially sustained the fall on 10/17/2023 and was suffering with a swollen left ankle. It was learned that the responsible parties were not made aware of the incident and reason for the hospital visit until the actual date of the appointment on 10/30/2023. It was further learned that this facility, and it's representatives, admitted that there was a breakdown in communication with R1 and R1's responsible parties in connection to this fall that took place on 10/17/2023 and they should have been informed in a timely manner. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties as well. Exit Interview Based on a review of the medical records, it was not discovered that R1 had suffered a fracture of R1's left foot until 10/30/2023 when R1 was taken to the hospital by R1's responsible party. An x-ray was performed since R1's left ankle was swollen and it was discovered that R1 had, in fact, suffered a fracture of the distal fibula in R1's left foot. Since almost two weeks had elapsed before this x-ray was performed, it was not definitive whether the initial fall on 10/17/2023 was the leading cause for the fracture since medical treatment was not sought at the time of the fall at this facility. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview