Regarding Allegation: Facility staff did not seek medical attention in a timely manner. It was alleged, a resident fell at the facility and sustained an injury, staff did not properly assess resident after the fall, and staff did not obtain timely medical attention for resident.

The investigation consisted of the Departments review of resident #6 (R6) facility file, incident reports, medical records, review of local law enforcement report, interviews with eight (8) residents, nine (9) staff, and witnesses.

On 06/25/2020 around 11:30PM. staff found R6 on the floor in resident’s room. Upon staff observing resident on the floor, staff stated that they assessed R6 for injuries and assisted R6 back to bed; staff observed R6 to have an abrasion to R6’s forehead, top of head, right arm, and left knee.

The investigation revealed the following: Interviews with eight (8) of eight (8) residents, revealed all eight (8) residents could not corroborate the allegation.

Interviews with nine (9) of nine (9) staff revealed that eight (8) of nine (9) staff denied the allegation. One (1) of nine (9) staff reported the facility’s Fall Protocol for residents is for staff to call 911 if a resident sustains an injury, or has signs and symptoms of pain after a fall. One (1) of nine (9) staff reported that the staff should not have moved R6 after the fall, and staff should have called for emergency services immediately after the fall. Interviews with two (2) of nine (9) staff reported to not be aware of the facility’s Fall Protocol for Hospice residents, and staff reported the facility Fall Protocol for residents on Hospice is to call Hospice first, therefore, the staff contacted R6’s Hospice staff and did not call 911 immediately.

Review of facility progress notes dated 06/25/20 indicate, that R6 suffered a fall on 06/25/20 at approximately 11:30PM, and R6 sustained injury to forehead, top of head, right arm, and left knee. Facility staff called Hospice, and Hospice staff arrived at the facility on 06/26/20 at approximately 2:30AM to assess R6. Per facility incident report dated 06/26/20, the Hospice assessment was abnormal. According to facility progress notes, at 7:45AM on 6/26/20, staff went to R6’s room to get R6 ready for breakfast and observed R6 to have a change of condition, slurred speech, and gargled breathing. Staff contacted R6's family for guidance regarding sending R6 to the Emergency Room for medical treatment. R6s family requested for staff to transport R6 to the Emergency Room. Facility progress notes dated 06/26/20, indicated staff called 911 at 8AM to transport R6 to the hospital emergency room.

Based upon the investigation, interviews conducted with facility staff, residents, and a review of documents collected from residents’ facility files/progress notes, staff failed to obtain immediate medical attention for R6, and did not call 911 after R6 suffered a fall in the facility resulting in injury. The injury to R6 was unrelated to resident’s Hospice services.

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The facility has been informed that Immediate civil penalty is being issued on today visit in the amount of $500.00, based on health and safety code 1569.49.

“The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).“

An exit interview was conducted with the Executive Director Daisy Hernandez and a hard copy of licensing report was provided along with appeal rights.

The investigation revealed the following: Interviews with eight (8) of eight (8) residents, revealed all eight (8) residents could not corroborate the allegation.

Interviews with twelve (12) of twelve (12) staff revealed that 12 of 12 staff denied the allegation, and reported to not be responsible for residents’ death.

Department interviews with staff regarding the resident’s fall revealed, that resident #6 (R6) had history of falls, and was on Hospice. On 06/25/2020 at approximately 11:30PM, staff found R6 on the floor in resident’s room. Upon staff observing resident on the floor, staff stated that they assessed R6 for injuries and assisted R6 back to the bed. Staff observed R6 to have an abrasion to R6’s forehead, top of head, right arm, and left knee. Per facility progress notes dated 06/25/20, staff contacted Hospice. Staff made attempts to contact R6’s family members, and contacted R6 family member the morning of 06/26/20. Staff discussed R6 fall/injury with R6's family member, and asked R6's family member if R6 should be taken for medical treatment. R6 family member requested staff transport R6 to the hospital for medical treatment. Upon R6 arrival to the hospital, R6 family member made the decision to intubate R6, and the physician explained medical options to the R6 family; including the option for surgery to repair R6 fractured neck. After R6 family members considering the treatment options, R6 family members decided to not go forward with the surgery. Therefore, based upon the investigation, there is insufficient evidence to support that the facility caused the residents death.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.