Complaint·January 27, 2023

Continued from 9099... On 05/02/2021, R1 was seen at the John Muir Concord Medical Center for chief complaint of "back pain." R1 was diagnosed with a closed non displaced fracture of the greater trochanter of right femur. Thickening of the right gluteus maximus was noted, which suggested infiltrative hematoma. John Muir Concord Doctor believes the hip fracture and hematoma on the buttock are likely a result of a fall or similar type of trauma to the posterior. On 05/27/2021, R1 was sent to John Muir Concord Medical Center after an unwitnessed fall in the bedroom. Staff 1 (S1) reported that after R1 was tucked into bed, S1 went to assist another resident. S1 heard a sound in R1’s room. S1 immediately responded and witnessed R1 was slouching on the floor and bleeding from the head. R1 was immediately sent to the hospital. R1 had a head scan which showed acute left subdural hematoma with a 4mm left to right midline shift. On 05/28/2021, R1 was transferred to John Muir Walnut Creek Medical Center and was admitted to the Intensive Care Unit for a neurosurgery evaluation. Another head scan was conducted, and the subdural hematoma increased to 1.3 cm. File review documents and staff interviews conclude that R1 was a fall risk resident. R1 was unsteady while ambulating and sitting down. Fall mats and bed alarms were briefly used but were not successful and as such discontinued. Another fall prevention strategy was reminding R1 to use walker and reminding R1 to sit down. Staff stated that R1 required constant monitoring and supervision. R1 did not have one to one care. Some of the staff reported that R1 would have benefited from one to one care. S2 stated that R1 was beyond a level of care that the facility could provide based on R1’s need for constant supervision. R1 passed away prior to being interviewed. Death certificate lists his date of death as 06/05/2021 at 2210 hours. Immediate cause of death is listed as Traumatic Subdural Hematoma. Condition leading to the cause of death/underlying cause is Ground Level Fall. Continued from 9099C... Based on interviews and record review, the above allegation is substantiated. A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending. A Non-Compliance Conference (NCC) will be scheduled. 2. Staff mishandled a resident's medications while in care During the course of investigation, LPA L. Fontanilla reviewed facility medication list, nursing report and RCEB QA Review. On 3/29/2021, a medication error was recorded by Nursing Manager Ashton Paul when R1’s PRN suppository was not given as prescribed. A review of R1’s Medication Administration Record (MAR) from March 2021 to May 2021 show that R1’s PRN medicine Bacitracin ointment was not administered throughout the months of March and April 2021. Instructions indicate “apply as needed to open wounds or skin tears until healed.” Bacitracin was administered on May 1, 8, 21 and 26, 2021. A review of RCEB Home Annual Review indicate there were three (3) medication errors reported for 2020-2021. Based on record review, the above allegation is substantiated. 3. Resident is being financially abused On 8/12/2022, LPA L. Fontanilla reviewed an incident report dated 02/16/2021. The report indicates that R1 is missing $100 from P&I money. When staff counted the amount of cash in R1 and other clients’ binder, a significant amount of money was missing from R1’s and all the other clients’ P & I money. The above allegation is substantiated. Continued on 9099C... Continued from 9099C... 4. Facility failed to follow residents care plan Based on interview conducted with Reporting Party (RP), after R1 was diagnosed with a hip fracture, facility staff and Regional Center of the East Bay (RCEB) staff created a plan that bed alarms would be useful for R1. Facility staff reported that bed alarms and floor mats were implemented for R1’s safety but were unsuccessful and discontinued. Facility staff reported that R1 repeatedly unplugged the bed alarms. Based on interviews conducted, the above allegation is substantiated. Exit interview conducted a copy of this report and Appeal Rights was provided.