complaint·March 16, 2022

Continued from LIC9099 An additional fall occurring February 2021 for R1 was self-reported by the facility. Per interview, resident’s fall was unwitnessed, and resident did not have any obvious injuries but did have a slight limp. The following day, resident was assessed by hospice and was able to move their extremities however, later the same day, R1’s family member reported to hospice that R1 was not able to move. A second call that day from the facility to hospice indicated that R1 was having additional pain. R1 was reassessed by hospice and sent to the emergency room. Staff interviewed revealed that, generally, hospice is called when a hospice resident sustains a fall unless the fall is severe. Per facility's "What to do when a fall occurs," document, if there is pain or bleeding, call 911. The allegation Neglect/Lack of Care: Staff did not call emergency services when resident sustained fractures is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. Additional Civil Penalty pending review per H&S Code Section 1548(d). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Continued from LIC9099A The day resident passed, the facility called hospice and reported a general decline and shortness of breath. Staff were instructed to elevate resident and call hospice if conditions worsen. When hospice called the facility later, the facility reported resident having shallow respirations and unlabored breathing. Resident passed while facility staff was on the phone with hospice. Facility failed to follow reporting requirements – Complaint alleges that staff did not notify the responsible party timely when R1 sustained a fall in September 2020. Facility reported that on the day of the fall, the resident’s family arrived at the facility for a routine visit within 30 minutes of the fall and the facility had not yet had the opportunity to call the family about the fall before they arrived at the facility. This agency has investigated the complaints alleging Neglect/Lack of Care: Staff failed to call for emergency services when resident passed away and Facility failed to follow reporting requirements. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.