Staff 2 (S2) informed that R1's wrist was swollen, bruised, and R1 stated, "Ouch", pointing to their wrist multiple times, but did not appear to be in extreme pain. Staff 3 (S3) stated that R1's wrist was swollen, not bruised, and R1 moaned slightly upon their wrist being moved, but did not seem to be in extreme pain. Staff informed that R1 was diagnosed with a wrist fracture at the hospital later that day.

Outside source interviews were conducted with R1's Responsible Person and Emergency Contact regarding the incident (OS1 and OS2). The outside sources informed that they were notified of R1's wrist injury and were subsequently present the morning of incident and took photos of R1's swollen/bruised wrist. OS1 and OS2 informed that the facility contacted R1's hospice agency for assessment, but due to the Labor Day holiday the hospice agency was unable to provide an on-site x-ray until 09/02/2025, which would have been two days after R1's injury. Facility staff then requested an x-ray order from R1's hospice doctor so the facility-contracted x-ray company could conduct an on-site x-ray, which would have taken an additional 3-4 hours. The outside sources inquired if it would be faster for R1 to be seen in the emergency room rather than wait for the mobile x-ray, to which staff affirmed. OS1 and OS2 then transported R1 to the hospital themselves. The outside sources informed that upon initial notification of R1’s injury, staff informed that R1's injury was not severe, and the facility did not offer to send R1 to the hospital the day of incident. The outside sources informed that R1 suffered a delay in medical care due to the attempts to secure an on-site x-ray instead of sending R1 to the hospital directly.

Review of facility records evidenced R1's wrist to be swollen, bruised, and showing evidence of pain. Facility Care Notes the day of incident stated, "Resident woke up with a swollen L hand. Seems to be painful to touch. Slight bruising noted." The Unusual Incident/Injury Report submitted by the facility regarding the incident stated, "On 08/31/2025 at 6:00 AM resident seen and examined during grooming and dressing rounds by caregiver. Resident was up walking in [their] room. Caregiver noticed [their] L hand/wrist was very swollen. Called nurse to assess. Some pain to touch." The Unusual Incident/Injury Report further stated that R1 did not recall what happened and the cause of injury was not apparent, R1’s bed was in the low position, R1's Responsible Party (RP) was made aware, R1 was given pain medication, and the hospice nurse assessed R1's wrist. The report further informed that RP drove R1 to the hospital rather than wait for mobile x-ray and assessment by on-call hospice doctor. Photos taken day of injury of R1's wrist showed swelling and purple discoloration to the inner side of R1's wrist and thumb. The facility sent a fax marked as urgent to R1's hospice agency with communication that informed of R1's swollen left hand stating, "Seems to be painful to touch" and that a photo of R1's wrist was sent. (Continued on LIC9099 p.3)

The facility requested advisement from R1's hospice agency. A visit note from R1's hospice agency on 08/31/2025 stated, "L wrist is swollen w/bruising inside thumb area. No apparent signs of pain. Pt able to use hand evidenced during the meal… able to hold fork w/o signs of complications." The visit note stated that R1's hospice doctor was notified and the hospice nurse was awaiting new orders to rule out fracture, as they were "not able to fully assess articulation". In different handwriting at the bottom of this hospice note was written, "1102 A.M. [RN] called, per MD, no new order, continue to monitor" and "1345 [POA] took [R1] to ER for x-ray." Facility Care Notes on 08/31/2025 additionally stated that R1 left for the ER at 1:45pm. The Emergency Room Report on 08/31/2025 showed that R1's arrival time to the hospital was 1418. R1's medical records for this admission showed that R1 suffered an "Acute displaced and angulated intra-articular distal radius fracture."

R1 was unable to be qualified as a valid historian for interview due to cognition.

Interviews and records showed that R1's injury was first observed at approximately 5:40am, the facility attempted to assist R1 by contacting R1's hospice agency and requesting approval for the mobile x-ray. The time elapsed between the injury being first observed and R1 leaving with OS1 and OS2 for the hospital was approximately 8 hours, 5 minutes. Records and interviews evidenced that R1’s wrist showed signs of bruising, swelling, and R1 indicated pain by pointing to their hand, stating “Ouch” multiple times and moaning when their wrist was moved. The evidence does not show that the facility attempted to assist R1 with a more expedient form of medical care such as calling 911 or an ambulance for direct medical transport to the hospital. The evidence shows that the facility continued to attempt to obtain an on-site x-ray for R1 after R1's hospice agency informed that their on-site mobile x-ray would not be available for two days. The evidence shows that R1's responsible party and emergency contact made the decision to have R1 go to the hospital in lieu of waiting additional time for the mobile x-ray, and transported R1 to the hospital themselves.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Executive Director Natasha Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

A hospice nurse also came to the facility once per week to conduct overall assessments. Although R1 was ambulatory and their family requested for R1 to walk for exercise, R1 additionally had a wheelchair to further reduce falls. Staff consistently informed that R1 was brought out to the dining room/activity area during the day for increased staff supervision and meals with other residents. Staff informed that R1 was checked on approximately every 2 hours for toileting with status checks in between, per their care plan. The incident in question occurred during NOC shift between approximately 4:00am and 5:40am. The staff member (S1) who first observed R1's wrist to be swollen informed that R1 was sleeping during the 4:00am status check, but was observed awake, standing, and holding onto a rail in their bathroom during the 5:40am check. At the 5:40am check, S1 noted R1's swollen wrist while assisting R1 with toileting, and R1 did not answer when asked what happened that caused the injury. S1 then elevated the observation to the on-shift supervisor and informed the oncoming AM shift caregiver.

R1 was unable to be qualified as a valid historian for interview due to cognition.

Outside source interviews were conducted with R1's Responsible Person and Emergency Contact. The outside sources reported that R1 suffered frequent falls at the facility, most of which were unwitnessed and resulted in minor injuries without the need for medical attention. The outside sources confirmed that R1 was placed on Hospice and utilized a wheelchair as well as a low hospital bed with half rails.

Records review corroborated staff statements. R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) showed that R1 suffered from a major neurocognitive disorder and recurrent falls. R1's Resident Care Summary listed that R1 needed assistance with Activities of Daily Living (ADLs), minimal help with transfers, and moderate help with mobility such as one-person assistance, hand holding, monitoring/assistance with using assistive devices due to noncompliance, escorts to meals/activities, and safety checks 4 times per shift. R1's Hospice records showed that R1 was admitted into Hospice due to worsening in condition, restlessness, weight loss, and frequent falls.

The evidence shows that the facility, with the support of R1's family and Hospice, took several steps to mitigate R1’s falls due to their declining health. The evidence additionally shows that status checks for R1 had been conducted by staff prior to the incident. In addition, it remains unknown how R1's injury occurred, since they were not found on the floor and were unable to explain what happened due to cognitive impairment. (Continued on LIC9099 p.3)

Based on interviews, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Natasha Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.