Complaint Investigation Report

Allegation: Staff did not seek medical attention for resident in a timely manner.

Based on interviews and record reviews, the facility did not seek medical attention in a timely manner for resident (R1). Despite complaints by R1 of severe back pain for 2 days (Hoyer fall incident occurred on 02/06/21 at 0830 hours), the facility did not send R1 to the hospital until 2 days later (911 was called on 02/08/21 at 0900 hours). Hospital discharge summary shows R1 was diagnosed with a lumbar spinal compression fracture. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Staff did not assist residents with ADLs in a timely manner.

Based on interviews conducted during investigation, staff (S1) stated residents are not being assisted in a timely manner due to insufficient staffing resulting in medication, feedings, showers, diaper changes and activities of daily living (ADLs) being done late or not at all. Resident (R2) stated that the facility was sometimes short staffed which affected the response time of the caregivers. Witness (W1) stated resident (R3) has lived at the facility for 2 years and 2 months. W1 stated that staff did not respond in a timely manner when R3 pressed her call pendant. R3 has had to wait 30 to 45 minutes for staff to respond. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.