Incident investigation·August 2, 2023

On 8-2-23 at 1:05pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding an incident which occurred on 7-8-23. LPAs met with Administrator Orchid Damrichob and explained the purpose of the visit. LPAs reviewed incident report dated 7-10-23, physician's report for resident1 (R1), needs and service plan for R1, LPAs also interviewed Administrator. Based on record review and interview, it was revealed that R1 sustained an unwitnessed fall on 7-8-23 resulting in a hip fracture. It was further revealed that after discovery of the fall facility staff notified hospice and sent R1 to hospital after receiving consent from R1's responsible person. Additionally, based on interview and record review, R1 was and continues to receive hospice services and has a history of agitation and wandering. Needs and service plan reviewed revealed R1 requires constant supervision, supervision with ADLs, and assist with all ADLs including toileting. Based on review of incident report, facility staff heard a call for help from R1 and found R1 on floor, called Administrator and assisted R1 back to bed. A review of hospice waiver states facility will provide additional staff as necessary to meet needs of residents in care. During the incident on 7-8-23, 1 care staff was on duty for 6 residents. Two of six residents received hospice services, multiple other residents have dementia care needs and incontinent needs. As a result of today's case management, citations are issued under Title 22, Division 6 and Health and Safety Codes. A civil penalty in the amount of $500 is issued in addition to citation due to injury relating to violation of Health and Safety Code Section 1569.312(a). At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was conducted with Orchid Damrichob and a copy of this report was left with Orchid. Appeal rights provided.