Complaint Investigation Report

3:30 AM. Staff found R1 on the floor yelling for help due to the pain. Staff lifted R1 from the floor and placed back in bed. Staff did not notify the administrator or hospice until 8 AM. Hospice nurse assessed R1, and caring physician ordered mobile x-ray service. Mobile x-ray services were conducted on December 3, 2024, at 3:30 PM. Results reflecting a fractured left hip were received at 4:55 PM. Interview with staff revealed that they were instructed to notify hospice first when a resident is under the care of a hospice agency. Staff did not call 911 when R1 was found on the floor in great pain and discomfort. The staff lifted the resident off the floor in pain and placed the resident back in bed with no regard for the seriousness of their pain and possible injury.

During the course of the investigation, there was sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, this allegation is deemed Substantiated.

See LIC-9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations and the assessed immediate civil penalty in the amount of $500.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).

An exit interview was conducted with the Administrator, and a copy of this report, Appeals Rights, and LIC-421IM Civil Penalty Assessment and the LIC-811, identifying confidential names were provided.