Complaint·September 20, 2022

The fall was heard by a visitor who notified a nurse. At approximately 1:20 pm, the nurse responded and saw R1 was sitting on their walker and was unable to bear weight due to left hip pain. 9-1-1 was called and R1 was transported to the hospital. Due to the fall, R1 sustained a fractured pelvis. The incident report indicates an in-service training with memory care staff regarding emergency procedures, including an elopement drill, was scheduled. According to the Administrator, Staff 1 (S1) failed to fulfill their assigned duties and did not have their pager during the incident and S1 did not respond to the WanderGuard activation. S1 was terminated as a result of this incident. Based on the information obtained, a lack of supervision resulted in R1 wandering out of the memory care unit and throughout the facility grounds. Additionally, due to the lack of supervision, R1 sustained an injury as a result of the lack of supervision. Therefore the allegation that lack of supervision resulting in resident wandering away from facility is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted. Civil Penalty issued. Copy of report and Appeal Rights issued via email.