On September 25, 2020, the Department concluded a complaint investigation and substantiated an allegation that the facility failed to seek timely medical for a resident (R1). The licensee was cited for violating Health and Safety Code, §1569.269(a)(6) Enumerated Rights for failure to seek timely medical for R1 after an unwitnessed fall resulting in a hip fracture and hospitalization.

During the Department’s investigation a timeline was provided by the facility to capture a sequence of events from R1’s admission to the facility on March 3, 2020 to May 13, 2020. The timeline states on May 8, 2020, R1 was found on the floor and complaining of pain of their right leg. Facility staff informed R1 that R1 would be transported to the hospital, R1 with a dementia diagnosis, refused. Facility staff contacted R1’s family member (I1) at 8 a.m. to inform them of R1’s fall and that R1 would be transported to the hospital. I1 refused the hospital transfer and informed staff that I1 would transport R1 to the hospital. Staff followed the direction of I1 and applied a cold compress and gave R1 pain reliever. Per I1’s statements, the facility did not tell them regarding transporting R1 to the hospital. Based on the timeline, at 4 p.m. I1 had not arrived at the facility to transport R1 to the hospital. Facility staff contacted I1 and was informed that I1 would transport R1 first thing in the morning on May 9, 2020. On May 9, 2020, I1 arrived at the facility, dropped off medication, then left without R1. Per I1, they weren’t allowed access to the facility due to COVID restrictions. R1 was not transported to the hospital until May 10, 2020, when another family member (I2) advised the facility to contact 911.

On May 10, 2020, R1 was admitted to the Intensive Care Unit (ICU) with a diagnosis of acute respiratory failure and a hip fracture. In addition, noted in the medical records; pain managed well with morphine, yet patient experiences severe pain with position change.” R1 was scheduled to have surgery on their right hip on May 13, 2020. However, prior to the surgery on May 12, 2020, R1 succumbed to acute respiratory failure, poor functional status and pneumonia.

Continue report see LIC809-C

When the findings were delivered on September 25, 2020, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, July 27, 2023 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on September 25, 2020, the amount of the civil penalty issued today will be $9,500.

A copy of the LIC 421D was given to Office Manager, Aurelia Renta and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Aurelia Renta, Office Managers signature on this report acknowledges receipt of these rights, found on page two of LIC 421D.