Complaint·February 25, 2025

S2 who was on the AM shift admitted that he/she should have called 911 immediately after resident had a fall and complained of pain, however indicated because resident was not in severe pain, S2 did not call 911. S1 who was on shift during the PM shift, indicated he/she was not sure why the facility did not send R1 to the hospital after the fall in the morning. The facility did not send R1 out to the hospital till about 5:30pm when R1 started moaning, complaining of pain, and couldn't move his/her legs. Based on medical records reviewed, due to the fall, R1 sustained a left hip fracture. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties. AN IMMEDIATE CIVIL PENALTY OF $500.00 WAS ASSESSED TODAY: $500 FOR THE VIOLATION AS STAFF DID NOT SEEK MEDICAL ATTENTION FOR A RESIDENT. THE ADMINISTRATOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49. According to the administrator and the Director of Health Services, the facility's protocol is to have the shift nurse call responsible parties regarding incidents that occur before they leave their shift. The facility did notify R1's responsible party based on interview conducted with S2, administrator and Director of Health Services. Based on care notes reviewed, it was observed that S2 did contact R1's responsible party. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. Report is reviewed with the administrator and a copy is provided.