Complaint Investigation Report

Regarding the allegation: “Staff did not provide timely medical care. This complaint alleged that staff did not seek timely medical care for R1 who was in pain after an unwitnessed fall. Record reviews revealed the following: R1’s Physician Report (dated 08/07/2023) indicates that R1 was diagnosed with mild cognitive impairment, was non-ambulatory due to physical condition and requires a walker. The facility’s incident report indicates that on 01/20/2025 at 11:45 a.m., R1 was observed screaming in pain after an unwitnessed fall. Staff assessed R1, and that 911 was not called. The Los Angeles Fire Department emergency response records indicate that first responders arrived at the facility at 5:02p.m. on 01/20/2025. Hospital medical records indicate that on 01/20/2025 at 5:29 p.m. R1 arrived and was diagnosed with a Fractured Back, Urinary Tract Infection and Brain Bleed. Interviews revealed the following: On 01/20/2025 around 11:30 am S6 reported hearing R1 screams for help from R1’s room. S6 informed S7 of R1’s fall, S7 evaluated R1 and noted complaints of pain to R1’s back, S7 gave R1 Tylenol and staff lifted R1 from the floor and placed R1 on the wheelchair. At around 2:00 p.m. S8 called W1 to report that R1 was in pain and that the pain increased. On 01/20/2025 at around 4:30 pm W1 found R1 screaming in pain and asked staff to call 911. It took approximately five and a half (5 ½) hours for R1 to get medical attention. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide timely medical care” is found to be SUBSTANTIATED.