Incident investigation·October 6, 2022

Licensing Program Analyst (LPA) arrived unannounced to follow up on a self-reported incident. LPA met with Mike Chapman, Operation Specialist (MC). It was self-reported to Community Care Licensing that on 9-12-22, resident (R1) had an un-witnessed fall in their bedroom. (R1) complained of pain. Staff (S1) contacted the responsible party, who denied to take (R1) to the hospital or for them to contact emergency services. Facility staff were unable to medically assess resident and whether they needed treatment. R1 had an additional fall the next day and complained of pain. Facility staff then contacted emergency services. Therefore the facility delayed seeking medical treatment for resident (R1). The un-witnessed fall did not result in any injuries. LPA reviewed resident records and interviewed resident and staff. LPA made observations with MC. LPA and MC learned that R1 had multiple falls due to the framework of their bed. MC will have a care conference with R1's responsible parties and discus alternative's to prevent the resident from falling out of bed. In addition, all staff will undergo an in-service of when to seek emergency medical treatment for residents and send proof to LPA by POC due date. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.