complaint·December 30, 2024

It was also stated that it was observed that R1 was not at their baseline of consciousness as they were unsure of how they fell and stated they were in a different town other than where they currently resided. It was learned that R1 has a diagnosis in which can impede in the resident’s decision making. After 20 minutes passed, facility staff contacted R1’s responsible party and notified them that R1 fell however will not be sending because of R1’s refusal. R1’s responsible party asked why the facility was not sending out R1 and staff stated that R1 could refuse medical emergency regardless of the resident’s current state. After 20 minutes, R1’s responsible party persuaded R1 to go to the hospital to obtain medication attention. A review of the facilities plan of operation was conducted. It states that under medical emergencies that if a resident show any sign or symptom of distress including but not limited to shortness of breath, chest pain or change of level of consciousness, emergency medication services will immediately be summoned. Based on the information gathered, the facility staff did not seek medical attention to a resident in a timely manner. Allegation: Staff did not notify CCL of incidents It was alleged that the staff did not notify CCL of incidents. During the course of this investigation, interviews were conducted and facility records were reviewed. Based on interviews conducted it was learned that R1 fell on 06/18/2024 and was sent out to the hospital and diagnosed with a hip fracture. Subsequently, on 07/26/2024, the R1 fell a second time and was sent out of the facility after R1’s responsible party convinced for the resident to go obtain medical services. An interview with the facilities Health and Wellness Director was conducted and it was learned that the facility was unsure when to send out incident reports when a resident frequently falls. LPA was able to obtain an incident report for the fall on 06/18/2024 and 07/26/2024 from the facility on 08/13/2024, however did not have an attached fax confirmation sheet. The facility was unable to provide proof that this incident report was sent via email or fax. A review of the departments facility records do not have any incident reports regarding any type of incident regarding R1 within the months of June and July 2024. In addition, a review of the R1’s care notes do not have documented falls within the months of March 2024-August 2024. Based on the information gathered, the facility staff did not notify CCL of incidents. Based on the information gathered, the facility staff did not notify CCL of incidents. Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged. Citations are being issued pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was provided. Based on the information gathered, it is unclear if the resident developed a UTI while in care. Based on the interviews conducted and a lack of documentation with law enforcement of a missing person the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were given.