Facility Evaluation Report

On 10/26/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced case management visit and met with Administrator, Agustin Samaniego. On February 24, 2022, the Department concluded a complaint investigation and substantiated an allegation that staff did not seek timely medical care for a resident (R1) resulting in R1 sustaining multiple injuries. The licensee was cited for violating Health and Safety Code, §1569. 269(a)(6) Enumerated Rights for failure to seek timely medical for R1 after an unwitnessed fall and Regulation 87466 for failing to report a change in condition when R1 developed bruising.

The investigation revealed that on August 28, 2021, per the “Response Time Report”, staff took approximately 35 minutes to respond to R1's pendent call for help. A further review of facility records "What to do when a fall occurs," shows that staff have been trained to call 911 for a resident who falls and is on a blood thinner. The facility failed to follow their own policy for R1 who had fallen and was taking blood thinner medication. The facility staff did not send R1 out for any medical treatment on August 28, 2021. Shortly after the incident of August 28, 2021, R1 began developing discoloration to their legs with no treatment being sought per facility notes. On September 2, 2021, facility staff found R1 unresponsive and R1 was then taken to the hospital for medical care. R1 was observed to have bruising on the left inguinal (outer left hip) area and ecchymosis at the umbilical area. Nurse Practitioner (N1) reported that R1's bruising could have stayed hidden for a few days but should have been noticeably worse by the fourth day after the fall of August 28, 2021. Upon discharge from the hospital on September 8, 2021, R1 was diagnosed with hemorrhagic shock secondary to hematoma in the iliopsoas muscle after an episode of a fall. R1 was also diagnosed with a left iliopsoas muscle hematoma, shock liver secondary to hypovolemia, right middle lobe pneumonia possible aspiration versus community-acquired pneumonia, acute kidney injury-resolved, and vertebral body 80% height loss with 8 mm retropulsion in the spinal canal with severe spinal stenosis.