Complaint·November 6, 2024

Regarding the allegation, due to lack of supervision, a resident had an unwitnessed fall resulting in a hip fracture, the Department reviewed documents and interviewed staff and residents. Based on documents reviewed and interviews conducted, R1’s unwitnessed fall was due to inadequate preventative measures and inaccurate assessments. The former resident service director inaccurately assessed R1, listing R1 as able to ambulate independently despite other documents stating R1 needed support. Based on staff interviews conducted, staff provided differing answers on whether R1 was a fall risk. In addition, according to the memory care director, it was noted that despite paperwork identifying R1 as a fall risk, there was no individualized fall prevention plan for R1, and short staffing led to the lack of supervision. Furthermore, the facility failed to follow up on the recommendation from R1’s responsible party for a walker. Regarding the allegation staff did not seek timely medical care for a resident, during the investigation, the Department reviewed documents and interviewed staff and residents. According to the staff interviewed, on 4/8/24 at around 6:10am, care staff assisted R1 into a wheelchair after finding R1 sitting on the bathroom floor. According to the care staff, it was noted that R1 was experiencing pain in his/her right leg or hip and called R1’s responsible party. Based on interviews, R1 was observed moaning and grimacing in pain when R1 moved his/her leg, however, staff attributed the pain to his/her old age and felt that 911 was not necessary. According to the memory care director, it was acknowledged that she was informed about the incident, however, did not follow up on R1’s status due to being busy with other duties. In addition, according to the med-tech who worked at night on 4/8/24 and in the morning on 4/9/24, it was admitted that after becoming aware of the incident on 4/8/24, he/she did not check on R1 on both days because she was busy. Furthermore, the med-tech indicated that 911 should have been called but they did not. Staff admitted to R1 being in pain but waited for the responsible party to come and visit. The lack of communication between staff and the short staffing at the facility delayed R1 from being sent to the hospital timely. 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 $1,000 IS ASSESSED TODAY: $500 FOR THE VIOLATION RESULTING INTO INJURY TO A RESIDENT AND $500 FOR THE VIOLATION AS STAFF DID NOT SEEK TIMELY MEDICAL ATTENTION FOR A RESIDENT. ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49. Report is reviewed with Resident Services Director, Mary Anne Rodriguez and a copy is provided with appeal rights. A copy of civil penalties are provided.