complaint·March 23, 2023

On 08/29/2022, between 2:27pm and 3:45pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a 10-day complaint visit to the facility. LPA De Leon met with Rebecca Michel, Co- Administrator and explained the purpose of the visit. The LPA requested documents pertinent to the investigation and took photos of the dining room area. The LPA determined further investigation was needed and would return on a later date to issue the final findings. LPA De Leon conducted interviews on 08/29/2022, from 11:23am to 2:30pm, with the Co-Administrator and R1’s resident representative. In addition, the IB Special Investigator Assistant (SIA) obtained and reviewed copies of French Hospital Medical Center medical records for R1. The facility file documents related to R1 were also reviewed. A review of the Special Incident Report (SIR) and the Co-Administrator’s written timeline of the incident revealed R1 was ambulatory without assistance and enjoyed walking freely around the facility. On 07/02/2022 after dinner, R1 continued to stay seated in the chair at the dining room table and dozed off. R1 fell out of the chair. Staff did not see R1 fall but saw R1 on the floor. Staff attempted to help R1 up and discovered R1 was in pain and not able to stand. Between 7:00 and 7:30pm, staff phoned the Co-Administrator, who was unavailable to come to the facility, but was able to FaceTime with the staff and observe R1 who appeared alert, eyes open and normal self. At approximately 7:45pm, the Co-Administrator phoned R1’s resident representative, who arrived at the facility shortly after and assisted the staff to get R1 off the floor, into the recliner to change, and assisted to bed. R1 was crying out in pain. At 9:00pm, R1’s representative texted the Co-Administrator to inform them that R1 was in bed sleeping and that R1’s left thigh area was swollen. The decision was made to wait until the morning to call 911 to see if R1’s condition was not improved or worsened. On 07/03/2022, at 7:30am, the Co-Administrator and R1’s resident representative observed R1’s hip area was very swollen. 911 was called and paramedics took R1 to French Hospital Medical Center. The complaint was referred to Community Care Licensing Investigations Branch (IB) to obtain R1’s medical records and to confirm that dates of the fall and when medical attention was received. On 08/29/2022, between 2:27pm and 3:45pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a 10-day complaint visit to the facility. LPA De Leon met with Rebecca Michel, Co- Administrator and explained the purpose of the visit. The LPA requested documents pertinent to the investigation and took photos of the dining room area. The LPA determined further investigation was needed and would return on a later date to issue the final findings. LPA De Leon conducted interviews on 08/29/2022, from 11:23am to 2:30pm, with the Co-Administrator and R1’s resident representative. In addition, the IB Special Investigator Assistant (SIA) obtained and reviewed copies of French Hospital Medical Center medical records for R1. The facility file documents related to R1 were also reviewed. On the allegation: Due to neglect, resident sustained a fracture while in care. A review of the Special Incident Report (SIR) and the Co-Administrator’s written timeline of the incident revealed R1 was ambulatory without assistance and enjoyed walking freely around the facility. On 07/02/2022 after dinner, R1 continued to stay seated in the chair at the dining room table and dozed off. R1 fell out of the chair. Staff did not see R1 fall but saw R1 on the floor. Staff attempted to help R1 up and discovered R1 was in pain and not able to stand. Between 7:00 and 7:30pm, staff phoned the Co-Administrator, who was unavailable to come to the facility, but was able to FaceTime with the staff and observe R1 who appeared alert, eyes open and normal self. At approximately 7:45pm, the Co-Administrator phoned R1’s resident representative, who arrived at the facility shortly after and assisted the staff to get R1 off the floor, into the recliner to change, and assisted to bed. R1 was crying out in pain. At 9:00pm, R1’s representative texted the Co-Administrator to inform them that R1 was in bed sleeping and that R1’s left thigh area was swollen. The decision was made to wait until the morning to call 911 to see if R1’s condition was not improved or worsened. On 07/03/2022, at 7:30am, the Co-Administrator and R1’s resident representative observed R1’s hip area was very swollen. 911 was called and paramedics took R1 to French Hospital Medical Center. A review of R1’s hospital medical records, revealed R1 was taken to the hospital by ambulance and admitted to French Hospital Medical Center on 07/03/2022 and diagnosed with a Left Intertrochanteric Hip Fracture. The records state R1 had a mechanical fall the day before where they fell backwards. Staff observed R1 seated at the dining table after dinner, R1 dozed off, and then sustained an unwitnessed fall resulting in the fracture. Based on the information obtained, the allegation “Due to neglect, resident sustained a fracture while in care” is deemed Unsubstantiated at this time. On the allegation: Staff did not report resident's fall to Community Care Licensing. The LPA reviewed a copy of the Special Incident Report (SIR) for R1’s fall on 07/02/2022 which resulted in a fractured left hip. The SIR is signed and dated 07/07/2022 and was faxed to CCL on the same date. The SIR lists an incorrect date the fall occurred as 07/03/2022. During today’s visit, the Administrator was advised to submit a corrected SIR with the correct date occurred as 07/02/2022. Based on the information obtained, the allegation “Staff did not report resident's fall to Community Care Licensing” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued. A review of R1’s hospital medical records, revealed R1 was taken to the hospital by ambulance and admitted to French Hospital Medical Center on 07/03/2022 and diagnosed with a Left Intertrochanteric Hip Fracture. The nursing assessment note at 9:18am states patient fell last night at memory care facility. The history of present illness notation explains R1 was “brought in by ambulance from their long-term care facility after a fall yesterday.” It goes on to state that R1 had a mechanical fall the day before where they fell backwards. R1’s resident representative was called and immediately went to visit R1. “R1 seemed to be OK, so they put R1 back in bed.” R1 did complain of some left hip pain from what they could tell and there was some swelling, but they decided to wait it out overnight as R1 appeared comfortable once in bed. The next morning R1 has continued to complain of pain and is unable to bear any weight. Ambulance was then contacted. The facility “Fall Prevention Practice at Garden House” was reviewed and indicated to call 911 when there is: profuse bleeding; blow to head; resident can verbalize they are in pain; can’t walk. After R1 fell on 07/02/2022, R1 verbalized they were in pain and could not stand up by self. R1’s immediate complaint of pain, inability to stand up by self and visible swollen thigh area on 07/02/2022 should have prompted the facility to seek timely medical attention which they did not. 911 was not called until the next morning on 07/03/2022. R1 was admitted to the hospital and diagnosed with a left hip fracture. Based on the information obtained, the allegation “Staff did not seek timely medical care for resident” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, deficiency cited, appeal rights discussed, and a copy of this report issued.