Complaint·July 17, 2025

Despite the facility being aware of R1’s behavior and condition, facility staff did not assist a Vitas Healthcare hospice aide on 12/2/24, leaving the hospice aide alone with R1. Facility staff interviewed acknowledged that facility caregivers did not help provide care to R1 when the hospice staff visited. According to the hospice aide interviewed, he/she transferred R1 alone despite staff knowing R1 required a two-person transfer. According to facility staff interviewed, it was indicated that even though there are two or more caregivers monitoring majority of the residents in the dining room throughout the day, residents can still fall. Based on R1’s medical records reviewed, the hospital noted R1 had a rotation to his/her left leg and a deformity to his/her left hip. Although R1 initially denied experiencing pain after his/her fall, R1 did complain of pain to his/her left hip and refused to eat. R1’s Computed Tomography (CT) scan showed an acute, mildly displaced fracture of the left iliac wing extending to the acetabulum with associated widening of the left femoroacetabular joint space; an acute, comminuted, mildly displaced fracture of the left inferior pubic ramus, and a mild presacral edema without a definite sacral fracture. A hematoma involving the left iliacus and left pelvic sidewall was also present on the scan. On 12/19/2024, R1 passed away. One of the primary causes of R1’s death noted on his/her death certificate was pelvic fractures (months). Regarding the allegation, staff did not seek medical attention to resident in a timely manner , according to the reporting party, on 12/2/24 at around 7am, Resident 1 (R1) fell and sustained a skin tear but was observed to be fine according to the hospice nurse. However, on 12/4/24, Vitas Healthcare hospice aide observed R1 in pain. R1 was taken to the hospital and was found to have suffered pelvic fractures in three different places. During the investigation, the Department reviewed R1’s file, medical records, and interviewed staff. Based on documentation reviewed, on 12/2/24, R1 had a fall while a hospice aide was present. R1 sustained a right arm skin tear and was treated by the hospice nurse. The h ospice nurse instructed staff to closely monitor R1. According to staff interviewed, it was noted that later in the evening of 12/2/24, R1 was constantly yelling for help. Staff 1 (S1) notified R1’s responsible party of R1’s pain and the responsible party requested for the med-tech to administer Tylenol to R1 as needed for pain , as R1’s responsible party believed that R1 might be hiding his/her pain. On 12/3/2024, Staff 2 (S2) indicated R1 was complaining of pain when changing R1’s diaper and reported it to the med-tech, however there was nothing documented regarding R1’s pain. Former staff member (S3) noted that R1 was constantly yel l ing for help,  was agitated all morning, and refused to eat his/her meals as he/she normally would. (continue to 9099C) It was not until the following evening on 12/4/24 that R1 was sent out to the hospital after S1 noted R1 complaining of left hip pain. Staff interviewed were unable to state why R1 was not sent out to the hospital earlier. Documentation reviewed showed that R1 was complaining of pain the night of 12/2/24, was constantly yelling for help, was noted to be more agitated than normal, and refused to eat signaling a change in condition. Regarding the allegation, staff did not communicate with resident's responsible party, according to the reporting party, after R1 had a fall on 12/2/24 at around 7am, the facility did not communicate with R1's responsible party regarding R1 complaining of pain. In addition, the reporting party stated that it was not until the hospice nurse called R1's responsible party on 12/4/24 and was told by R1's responsible party to send R1 to the hospital. During the investigation, LPA interviewed the administrator and reviewed R1's charting notes. According to the charting notes reviewed, Although, R1's responsible party was notified of R1's fall on 12/2/24 and notified of R1 not eating later in the evening, the facility did not communicate with R1's responsible party on 12/3/24, when R1 was constantly yelling for help and documented a change in R1's condition. According to the administrator, R1's responsible party was notified of R1's change of condition on 12/2/24 and indicated if a resident is on hospice, hospice instructs the facility not to call 911. Based on information collected, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are 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 $500 civil penalty is being assessed today as the facility did not provide adequate supervision resulting in R1 sustaining multiple fractures in care. A repeat civil penalty of $500 is being issued today due to the same violation ( 87464(f)(1) Basic Services ) being cited on 1/9/2025. Due to immediate civil penalty of $500 being cited and repeat civil penalty of $500 being issued, total civil penalty being assessed today is $1,000. An immediate $500 civil penalty is being assessed today as staff did not seek medical attention to resident in a timely manner. 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. Report is reviewed with Administrator and a copy is provided with appeal rights. A copy of civil penalties are provided.