Complaint·April 14, 2025

to 10:50 am, the LPA conducted a brief interview with the Administrator. The LPA informed the Administrator that further investigation would be conducted by the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Johnny Canto. On 10/12/2024, at approximately 9:40 am, Investigator Canto attempted to contact the reporting party; on 10/21/2024, from approximately 8:00 pm to 9:59 pm, conducted interviews with the Administrator and facility staff; on 10/22/2024, from approximately 8:10 am to 8:55 am, with residents and Resident 1 (R1); on 11/05/2024, from approximately 2:15 pm to 4:00 pm, with staff and the Administrator, and on 11/06/2024, at approximately 10:56 am, with former staff. In addition, Investigator Canto reviewed Santa Barbara Cottage Hospital medical records and facility file documents related to the investigation. The Santa Barbara Police Department (SBPD) also received a report of neglect and conducted a visit to the facility on 10/01/2024. A copy of the SBPD Report #2024-51627 was requested. A review of R1’s facility file documents revealed that R1 was admitted to the facility on 01/28/2024. According to the resident appraisal, dated 01/28/2024, R1’s diagnoses included A-FIB, breast cancer, endometrial cancer, GERD, Hyperlipidemia, and Hypertension. The appraisal indicated R1 did not have a current history of disruptive, aggressive, verbal, or socially inappropriate behavior, depression, anxiety, or mood disorder. No history of hallucinations or delusions. R1 can express self verbally, able to express pain verbally and with facial grimaces. R1 requires a supportive ambulatory device (walker). R1 requires total extensive assistance with transferring. R1 is considered at risk for falls, and appropriate interventions should be implemented on the service plan and a negotiated risk agreement completed. R1 will wear a wireless pendant for emergency calls. R1 requires physical assistance with toileting task; escorting transferring to the toilet and may need assistance in the use of incontinence supplies. Staff interviewed indicated R1 had sustained “several falls” and was a known fall risk. Staff interviewed also stated they believed R1 needed a higher level of care. Staff interviewed indicated if they claim a call button, they must respond, regardless of how many times a resident calls. Other staff interviewed indicated R1 pressed their call button so frequently, some stopped responding to R1’s calls. Additionally, Investigator Canto tested a resident’s pendant at random in the facility, and no staff responded after twenty (20) minutes of waiting. A review of the Santa Barbara Cottage Hospital medical records revealed R1 arrived at the hospital on 08/27/2024 at 11:25 pm with a chief complaint of head injury due to an unwitnessed fall. The injuries were noted as right facial 3 cm laceration lateral to right eye and hematoma over right scalp. R1 also appeared to Please continue to 9099-C, Pg 3. have a right wrist deformity and swelling. An x-ray confirmed a midshaft radius (wrist) fracture which required surgery. R1 had open reduction internal fixation (ORIF) surgery on 08/31/2024 and was discharged back to the facility on 09/01/2024. The Department’s investigation revealed that on 08/27/2024, R1 called for assistance through the facility’s call system (Sage Pendant), for assistance with the restroom. Staff #1 (S1) who worked the PM shift (2:30 pm to 11:00 pm) claimed the call for assistance; however, S1 did not attend to R1. When staff did not respond, R1 attempted to use the restroom on their own, fell, and hit their head. The last time R1 was seen without incident was at approximately 9:00 pm. At approximately 11:00 pm, at the end of the PM shift, S1 cleared the call for assistance without verifying the wellness of R1. Staff #2 (S2), who worked the overnight shift (11:00 pm to 6:00 am), received a call for assistance from R1. Upon entering R1's bedroom, S2 discovered R1 on the floor, with dried blood on the right side of the head. 911 was called and R1 was transported to the hospital. R1 sustained a facial laceration and midshaft radius fracture. A review of the Sage Pendant call system noted R1 called for assistance approximately five hundred (500) times. S1 was interviewed and stated S1 failed to assist R1 due to forgetting they had claimed the call for assistance and was focused on S1’s other duties. The facility failed to respond to R1’s calls for assistance and neglected R1’s care. Therefore, the allegation “Staff did not answer resident's call button in a timely manner, resulting in resident sustaining a fracture.” is Substantiated at this time. A $500 immediate civil penalty is assessed today. Administrator Glock was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.