The investigation revealed that on August 28, 2021, per the “Response Time Report”, staff took approximately 35 minutes to respond to R1's pendent call for help. A further review of facility records "What to do when a fall occurs," shows that staff have been trained to call 911 for a resident who falls and is on a blood thinner. The facility failed to follow their own policy for R1 who had fallen and was taking blood thinner medication. The facility staff did not send R1 out for any medical treatment on August 28, 2021. Shortly after the incident of August 28, 2021, R1 began developing discoloration to their legs with no treatment being sought per facility notes. On September 2, 2021, facility staff found R1 unresponsive and R1 was then taken to the hospital for medical care. R1 was observed to have bruising on the left inguinal (outer left hip) area and ecchymosis at the umbilical area. Nurse Practitioner (N1) reported that R1's bruising could have stayed hidden for a few days but should have been noticeably worse by the fourth day after the fall of August 28, 2021. Upon discharge from the hospital on September 8, 2021, R1 was diagnosed with hemorrhagic shock secondary to hematoma in the iliopsoas muscle after an episode of a fall. R1 was also diagnosed with a left iliopsoas muscle hematoma, shock liver secondary to hypovolemia, right middle lobe pneumonia possible aspiration versus community-acquired pneumonia, acute kidney injury-resolved, and vertebral body 80% height loss with 8 mm retropulsion in the spinal canal with severe spinal stenosis.

Continued onto LIC809-C

The Department 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." This is evidenced by medical record review and interviews; it was determined that the facility failed to provide proper care and supervision and delayed seeking medical attention for R1 resulting in serious bodily injury and hospitalization for hematoma from a fall.

Today, 10/26/2023 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 February 24, 2022, the amount of the civil penalty issued today will be $9,500.

A copy of the LIC 421D was given to (facility representative) and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided, Administrator, Agustin Samaniego signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.