Complaint Investigation Report

IB investigation and documents obtained revealed the following: Resident 1 (R1) was admitted to the facility on February 22, 2023. R1 physician report noted that R1 was non-ambulatory and suffered from dementia. The resident appraisal noted that resident was ambulatory (contradicted physician report), does not use a walker or wheelchair, but needs help with transfers and bathing, and was a fall risk. On February 28, 2023, at about 3 am, Staff 1 (S1) heard noises and saw R1 standing in the hallway and was taken back to bed. At around 6:30-7am, Staff 2 (S2) saw R1 on the floor near the bed. R1 could not get up on his/her own and needed assistance from staff. According to S1, the resident made a noise indicating being in pain. S1 asked R1 if it hurt and R1 pointed to the hip. Around 9am, the administrator contacted R1's POA to advise them of the incident and asked them to come and take the resident for an x-ray. The POA husband came to the facility about noon but was turned away by the staff because the resident was sleeping. Staff advised that they would contact the POA if the resident's status changed. The administrator texted the POA about 12:30pm and advised that the resident was still in pain. At 2:30pm, paramedics were called but they would not transport resident as they deemed it to be a non-emergency. On March 1, 2023 at 8:43am, the administrator texted the POA to get the resident an x-ray. The husband of the POA picked up the resident around 12pm and took him to urgent care for an x-ray. The resident returned to the facility pending the results. The following day March 2, 2023, they were notified that the resident suffered a fracture. The paramedics were called and refused to transport the resident as it was not an emergency. The administrator finally arranged for private transportation to the hospital. The resident went to the hospital and did not return to the facility.

On 09/03/2024, LPA Mora conducted a subsequent visit to gather additional information and obtained the following per interviews with Administrator, S1 and S2: there was no care plan for this resident and Administrator stated because there is no Title 22 regulation that says they have to have a care plan because they are not a medical facility. Administrator also stated that staff check up on the residents while they are awake and once the residents go to sleep the staff do not conduct additional checkup because this is not a 24-hour care and supervision facility. There are no staff awake and they are just there for emergencies. S1 and S2 both confirmed that they sleep at night. S1 sleeps in the caregiver room and S2 sleeps in the living room. S1 showed LPA that they have audio baby monitor in each of resident bedrooms, and they place one in the living room for S2 and one in the staff bedroom for S1. If they hear anything on the monitors, then they wake up to go assist the residents. Both S1 and S2 confirmed that they were asleep on February 28, 2023.