On March 9, 2021, the Department concluded the complaint investigation and substantiated the allegations that staff did not seek timely medical attention for a resident (R1); did not adequately supervise R1 who is a fall risk; failed to assess R1’s change of condition after a fall; and R1 died as a result of a serious fall at the facility. The licensee was cited for violating California Code of Regulations (CCR) Title 22, 87465 Incidental Medical and Dental Care due to the facility failing to call for medical care after R1 had a fall with a head injury on October 2, 2020; 87705 Care of Persons with Dementia due to the licensee not ensuring that a fall risk resident was adequately supervised by staff while seating in the common area as indicated in residents care plan; 87466 Observation of the Resident due to the facility not observing a change of condition in R1 after a fall; Health and Safety Code (H&S) §1569.269 Enumerated rights; severability due to the licensee not ensuring that R1 was accorded safe, healthful and comfortable accommodations which resulted in R1's death as a result of a serious fall at the facility.

Based on records reviewed, facility Special Incident report dated October 6, 2020, indicated, at approximately 3:15 p.m. on October 2, 2020, R1 was sitting in a recliner with their feet up and slid to the end of the chair. R1 fell, hit their head, and was found unconscious. The report submitted by the Administrator indicated that "staff would have R1 sit in an area where R1 could be visually monitored by staff" which was also documented in R1 's Needs and Services Plan, dated March 9, 2020. Interviews conducted on January 28, 2021, and February 8, 2021, revealed that the reporting party provided information that a non-facility staff had to bang on the main office window to get staff’s attention to assist R1 after the fall.

Continued on LIC809C...

Interviews with staff revealed R1 was assessed by staff (S1) after the fall. It took four staff to lift and transfer R1 who was unconscious, to their bedroom and provide an icepack. S1 contacted R1's responsible party and was told not to transport R1 to the emergency room (ER). The Licensee was interviewed and stated, "I happened to walk in the facility and decided to call 911 to transport R1 to hospital”.

Based on additional records obtained, R1’s Physician Report (LIC602) dated January 28, 2020, indicated R1 had a diagnosis of dementia. After the fall R1 was placed on hospice, R1 was released on hospice on October 6, 2020, and R1 passed on October 7, 2020. The death certificate issued on October 26, 2020, revealed the immediate cause of death is Intracranial hemorrhage.

At the time of the complaint visit, 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 an additional civil penalty is warranted for serious bodily injury that resulted in the death of a resident. The 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 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, August 2, 2023, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49, for a violation that the Department constitutes as a serious bodily injury that resulted in death in the amount of $15,000. However, since a civil penalty of $500 was previously issued on March 9, 2021, the amount of the civil penalty issued today will be $14,500.

Exit interview conducted. A copy of the report issued. Appeal Rights provided, (facility representative) signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.