Incident investigation·April 11, 2024

Licensing Program Analyst (LPA) conducted an unannounced case management visit following up on the visit conducted on 12/28/2023. LPA met with Administrator, Donna Lagman and stated the purpose of the visit. On 12/27/2023, the Department received an Incident Report from the facility stating resident (R1) had a fall in his/her bedroom and was transported to the hospital via 911. On 12/26/2023 at approximately 3am, R1 fell in the bedroom and rang the bell for assistance. R1 was taken to the hospital at approximately 9:05am and kept in the Intensive Care Unit (ICU) to monitor breathing and pain. On 12/28/2023, LPA conducted a visit and interviewed 3 staff and requested documentation. Based on the interviews conducted, 3 out of 3 staff stated the facility staff did not seek medical attention right away once R1 expressed pain was uncontrollable at approximately 7am and wanted to go to the hospital. Based on review of phone calls made between S1 and Administrator. S1 stated he/she needs to ask Administrator for permission to call 911 for residents. S1 stated Administrator will make the decision to call 911. At approximately 7:49am & 7:55am, Administrator called and left a voicemail to R1’s responsible party to take R1 to the hospital. At 8:53am, the Administrator texted S1 to call 911 and seek medical attention. The paramedics arrived at the facilty and transported the resident to the hospital at approximately 9:05am. Based on interview with S1 and S2, S2 admitted to sleeping during his/her shift as the awake night staff on 12/26/2023 and did not hear R1’s calling for help. S1 stated he/she was not working and was sleeping when he/she heard R1’s bell ringing. S1 stated he/she woke up S2 to check on R1. R1 had refused to go to the hospital at that time and requested PRN pain management medication. At around 7am, S1 stated that R1 was complaining of pain and S1 tried to contact R1’s responsible party and he/she did not pick up. Based on review of R1's LIC 602A Physician's Report dated 2/13/2023, the resident has diagnosis of Dementia. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. On 1/5/2024, R1 passed away at the hospital. Based on review of the Death Report, the cause of death was complications of rib fractures and unwitnessed fall. Deficiencies were cited per California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalties for the violation resulting in serious bodily injury is pending for further review. This report was reviewed with Administrator, Donna Lagman and a copy of the report was provided. Appeal Rights were provided.