Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/03/2023). According to the LIC624: Resident #1 (R1) fell on 04/23/2023 and initially refused to be transported to a hospital emergency room (ER). [See LIC 811 Confidential Names List for a description of R1.] Then on 04/28/2023, R1 complained to staff of “decreased mobility”; on this date R1 was transported to the ER, where they were diagnosed with “lumbar spine fractures.”

As of the date of CCLD’s visit, R1 had already moved out of the facility and could not be interviewed. During today's visit, LPA briefly toured the facility, reviewed pertinent care records, and interviewed relevant staff.

Per staff interview: Facility staff called 911 for R1 on 04/23/2023 (soon after the fall), but R1 refused to the paramedics to be transported to the ER. R1’s physician and responsible person were timely notified of the incident. Facility staff kept R1 under increased observation for the next 72 hours, without concern. Facility staff again called 911 for R1 on 04/28/2023, after new symptoms were reported. R1’s responsible person was also aware that R1 went to the ER.

Based on the information collected today, there does not exist a preponderance of evidence to show that Licensee did not arrange timely emergency Incidental Medical Care for R1. No deficiency was cited for this specific incident. No deficiencies were identified/observed during LPA’s visit today. However, LPA delivered a Technical Violation/Education regarding 87211 Reporting Requirements.

An exit interview was conducted with El-Rabaa, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.