Follow-up on corrections·May 5, 2021

Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20200901153501. The investigation revealed that when R1 was found on the floor on 8/26/2020 at 4 a.m. and was assessed by Staff #1 (S1), Resident #1 (R1) complained of generalized leg pain. Thinking that it was the same generalized pain in R1’s right leg known to the facility, S1 put R1 back to bed without further assessment. S1 did not call 9-1-1 or immediately inform the Administrator. At 8 a.m., the Administrator came to the facility and the Administrator inquired about R1, to which S1 informed the Administrator that R1 had fallen. While changing R1, R1 mentioned to the Administrator that they were in pain. Hospice was notified, and an x-ray was ordered. The portable x-ray was completed at 11:40 a.m. on 8/26/2020 and the fracture to the left hip was discovered. Based on the information obtained, staff failed to seek medical attention for R1 in a timely manner. When R1 communicated leg pain after being found on the floor, staff did not notify hospice or the Administrator until hours later. Thereafter, an x-ray taken at 11:40 a.m. revealed that R1 suffered a fractured left hip. After discussion with R1's family and R1's physician, 9-1-1 was called at 4:55 p.m. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's report and appeal rights were reviewed and issued via email. Signatures were obtained.