Incident investigation·September 12, 2024

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent Case Management-Incident visit. The purpose of the visit is to issue final findings related to the Case Management-Incident visit initiated by LPA Zabel Chochian on 03/20/2024. LPA Camara met with administrator Karthik Kanakaraj. Entrance interview conducted. On 03/15/2024, the Department received an incident report, noting that on 03/08/2024, Resident #1 (R1) suffered a fall in their private room, which resulted in a fractured hip and hospitalization. On 03/20/2024, from 3:00 p.m. to 5:00 p.m., LPA Zabel Chochian conducted a Case Management - Incident visit to the facility. During the visit, LPA Chochian and staff toured the facility at 3:15 p.m.; the LPA conducted a file review at approximately 3:30 p.m. and obtained pertinent documentation related to R1; and interviews with staff and the Administrator were held regarding the incident at approximately 4:00 p.m. The LPA determined further investigation was needed and informed the Administrator that the case was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Dennis Seng. On 05/15/2024, at approximately 10:45 a.m., Investigator Seng conducted an interview with R1’s resident representative; on 05/16/2024, from approximately 4:02 p.m. to 5:35 p.m., with staff, Administrator, and residents; on 07/11/2024, contacted Ventura Police Department (VPD) and was informed there was no incident report taken or on record for R1. In addition, Ventura Community Memorial Hospital (VCMH), Victoria Care Center, and Viva Home Health medical records and facility file documents related to R1 were reviewed. According to R1’s Preplacement Appraisal Information, R1 was diagnosed with schizophrenia. R1 was unable to manage their own treatment and has a mild cognitive delay. It lists R1 as unable to walk without any physical assistance. R1 is unable to use evacuation routes including stairs and is unable to quickly (continued on LIC809C) (continued from LIC809) evacuate. Per R1’s Physician Report, dated 09/19/2023, R1 also has unspecified dementia, and was listed as non-ambulatory. Under the Medical Emergencies portion of when to call 911, it states if a resident has fallen and may have broken bones, to call 911. Per R1’s Needs and Services Plan and Resident Appraisal, dated 09/07/2020, it shows R1 was diagnosed with COPD, Alzheimer’s disease, schizophrenia, hypertension, and dementia. The VCMH medical records revealed R1 was brought in by ambulance to the emergency room on 03/09/2024 at approximately 8:39 a.m. with the chief complaint of left hip pain. The records documented R1’s “pain is currently rated a "7/10" in severity. Patient’s increasing pain prompted today's Emergency Doctor’s visit for further evaluation.” The records further documented R1 sustained a left femoral neck fracture (hip fracture) after a mechanical fall when tripping over a wheelchair at their assisted living facility. R1 underwent left proximal femur open reduction and placement of a cephalomedullary nail with orthopedic surgery on March 9, 2024. On 03/14/2024, R1 was discharged to Victoria Care Center for further rehabilitation. Based on files reviewed and interviews conducted, the Department found sufficient evidence to prove that the facility was responsible for the neglect and lack of care and supervision of R1 by failing to contact medical services in a timely manner. This caused R1 to experience extended pain. R1 sustained a broken left hip from a fall dated 03/08/2024 at approximately 11:30 p.m. Facility staff both admitted to not calling 911 or notifying the Administrator of R1’s fall until the following morning on 03/09/2024 at approximately 8:00 a.m. Once the Administrator was notified of the fall, they immediately called 911 and notified R1’s resident representative. R1 was not taken to Ventura Community Hospital until 03/09/2024, at approximately 8:38 a.m. The facility staff both stated that the fall occurred at approximately 11:30 p.m. on 03/08/2024. They both admitted they should have notified the Administrator of the fall immediately and called 911 to have R1 checked, as R1 stated R1 was experiencing pain on their left hip immediately after the fall and complained of pain on several occasions throughout the night. Based on the evidence received from the facility staff, and the medical records; the department has sufficient evidence to determine that the facility staff did not obtain timely medical attention for R1. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Exit interview conducted, appeal rights provided, a copy of this report issued.