complaint·November 6, 2025

Staff sent hospice resident to hospital without authorization from POA or Hospice. - UNSUBSTANTIATED It was reported that after two falls staff at the facility sent Resident 1 (R1) to the hospital for imaging and told the RP it was the facilities policy to send out the resident. LPA reviewed an incident report dated 09/10/2025 which reports Resident 1 R1) complained of pain in left hip and shoulder following a fall. EMS evaluated R1 and transported to local hospital for further observation. Hospice was present and POA was notified. The facility planned to re-open R1 on hospice upon their return to the facility. Hospice stated on 09/09/2025 R1 had a witnessed fall at 09:00 AM with no injuries and an unwitnessed fall at 04:30 PM during which R1 hit their head and there was a bruise. An hour after the last fall hospice visited R1 and noted resident was oriented and alert stating R1 didn’t seem to have a concussion but had a contusion on the left frontal region of their head. All extremities working fine required assistance ambulating. R1 had a bruise on their left hip. No pain noted. On 09/10/2025 hospice visited R1 to follow-up and things were totally different. Hospice discussed the two falls and spoke with facility staff who stated R1 was not doing well, was in pain and very cognitively different and totally out of baseline. Hospice informed RP who did not want R1 sent out. Facility staff stated they had to send R1 out to be examined at the hospital due to suffering a head strike during the fall. Hospice informed facility staff that they needed to call the RP and inform. Hospice stated they had no choice at that point and the facility sent R1 out to hospital. LPA reviewed the admission summary for Oroville Hospital dated 09/10/2025 which states that the POA for R1 did not wish to have any further studies done. R1 was on comfort care and wanted R1 to return to the facility on comfort care. Facility staff requested R1 undergo hip x-rays to ensure there was no fracture. The hospital completed x-rays of both hips and found no fractures. R1 was returned to the facility on 09/11/2025. Continued on LIC9099-C Executive Director (ED) stated that R1 hit their head and complained of pain to their left hip after the fall. ED explained to the POA that they couldn’t force R1 to go to the hospital but if R1 wasn't evaluated for injuries at the hospital the POA would have to come and get R1 because they were in pain. ED stated If R1 had a brain bleed or broken hip, ED didn’t want the facility to be liable because R1 didn’t get the care they needed. It was determined that Resident 1 (R1) fell twice in one day and struck their head during the second fall. R1 had a change in condition the following day and was out of baseline. Due to R1 suffering a head strike the facility sent R1 out to be evaluated in case they had suffered serious injury. Hospice was present and RP was notified. This allegation is unsubstantiated. Staff didn't follow Hospice Care Plan- UNSUBSTANTIATED It was reported after the resident fell twice they were sent out to the hospital for imaging which was outside of the hospice care plan. LPA reviewed R1’s care plan which includes hospice care plan. The care plan states under pain management that staff are to report any changes in pain levels or the effectiveness of medication to the supervisor immediately. It was determined that Resident 1 (R1) fell twice in one day and struck their head during the second fall. R1 had a change in condition the following day and was out of baseline. Due to R1 suffering a head strike the facility sent R1 out to be evaluated in case they had suffered serious injury which was outside of R1’s hospice care plan. This allegation is unsubstantiated Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Stacey Baxter.