complaint·June 13, 2024

45 minutes. R1 stated they were banging on the door to let someone know they needed assistance. R1 stated their hand was getting numb from hitting the door and they had bruises on their hand, arm, and legs from trying to signal for help. R1 stated a visitor found them and summoned staff. R1 stated they have only pressed their pendant once or twice in the past. R1’s visitor signed into the facility at 5:39 pm, which was confirmed by visitor logs. Visitor went upstairs to R1’s room, where they heard R1 yelling for help. Visitor stated they went back downstairs to the front desk and asked for staff to open the door immediately. Staff told the visitor there was another emergency on the same floor. Visitor went back to the second floor and searched for another staff, who opened R1’s door and then left. Visitor stated R1 was in the bathroom, behind two closed doors, banging for help. Visitor left to find help and found a staff in the kitchen. The staff immediately called for help on the walkie talkie and went to R1’s room with the visitor. Staff called 9-1-1. Information from visitor and R1’s family member confirmed the visitor first called family at 5:58 pm, then 6:00 pm and 6:11 pm. The incident report submitted by the facility indicates R1 was discovered around 5:45 pm. Former administrator indicated the facility has a 10-minute response time to their call buttons. LPA reviewed facility call button logs. LPA observed an entry for 10/4/2023 at 5:12:46 pm where R1 pressed their pendant. It states it took 35 minutes and 3 seconds for staff to respond, at 5:47:49 pm. For the time period of 10/3/2023 to 10/4/2023, LPA observed 3 calls that were between 20 and 40 minutes, and 3 calls that were over 40 minutes. LPA also observed one call for a resident was listed at 117 minutes 4 seconds. An interview with a credible witness revealed they discussed call button times with the former administrator on 10/24/2023. Witness stated the staff have just been saying “Copy” but then do not respond to the call. Per witness, former administrator was going to change the policy to ensure staff responded promptly, or else another staff would be notified to respond. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Staff did not report an incident involving resident to their Responsible Party as required: It was alleged that the facility refused to provide R1’s responsible party a copy of the incident report. R1’s family member stated family met with the former administrator on 10/24/2023 to discuss the incident with R1. Former administrator indicated they were not able to release the written incident report to them due to corporate policy. A credible witness also indicated they were not able to obtain call button logs due to ‘corporate policy.’ Please continue to 9099-C, Pg 3. LPA reviewed the incident report for R1’s fall on 10/4/2023. The incident report states R1’s responsible party was called and notified but does not indicate they were notified in writing as required per regulation. Based on the information obtained, the allegation is deemed Substantiated at this time. Technical Assistance is also provided to remind the Administrator of section 87468.2(a)(19) Personal Rights, which states residents have the right “To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.” The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.