Complaint·March 16, 2023

The investigation revealed the following: Regarding allegation: Resident sustained a subdural hematoma while in care. It is alleged R1 was sitting in a wheelchair, being spoon fed dinner, and had a "very large hematoma" on the left side of R1's forehead. Per admission agreement, R1 was admitted to the facility on 6/26/21. Upon arrival administrator noted R1 was missing a medication. On 6/29/21 R1's responsible party was notified that R1 had "knocked head on the wall" over the phone around 9:00am. At around 5:30pm R1's responsible party arrived at the facility and took R1 to College Medical Center for medical care. R1 had a diagnosis of Dementia per physician's report dated 6/14/21. Medical records note that on 6/29/22 at 8:20pm, R1 was admitted to College Medical Center with chief complaint as suicidal ideation and unwitnessed abrasion to the forehead. A transfer from College Medical Center to St. Mary's Medical Center was arranged for R1 on 6/29/21 for higher level of care due to blunt head injury. R1 was admitted at St. Mary's Medical Center on 6/30/21 at 00:57am due to subdural hematoma. R1 went through two (2) procedures to assist with hematoma between 6/30/21 and 7/1/21. On 7/10/21 R1 was placed on hospice care due to R1's status. On 7/14/21 R1 passed away at the hospital. Death report revealed cause of the death was due to blunt head trauma. Administrator was interviewed and stated to have observed a "tiny redness approximately 1/2 inch on the left side of forehead." Per administrator R1 had restless behaviors for 3 days, such as lack of sleep and statements of wanting to "kill self". Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. Regarding allegation: Facility staff did not seek medical attention in a timely manner. It is alleged on the morning of 06/29/2021, the responsible party received a telephone call from the facility advising that the facility was going to call 911, but facility never called 911 and the resident was not transported to the hospital. On 6/29/21 at approximately 9:00am, R1's responsible party was notified that R1 had "knocked head on the wall". At approximately 5:30pm, R1's responsible party arrived at the facility and took R1 to College Medical Center for medical care. Medical records note that on 6/29/22 at 8:20pm R1 was admitted to College Medical Center with chief complaint as suicidal ideation and unwitnessed abrasion to the forehead. A transfer from College Medical Center to St. Mary's Medical Center was arrange for R1 on 6/29/21 for higher level of care due to blunt head injury. (CONTINUED ON LIC 9099C) R1 was admitted at St. Mary's Medical Center on 6/30/21 at 00:57am due to subdural hematoma. On 7/10/21, R1 was placed on hospice. On 7/14/21; R1 passed away at the hospital. Death report revealed cause of the death was due to blunt head trauma. Interview with administrator revealed, administrator contacted R1's responsible party in the morning and upon responsible party arriving they requested they will drive R1 to the hospital and administrator "should have called 911" instead. Based on interviews and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustained a subdural hematoma while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(e) - (f); if the department determines the death of the client is due to neglect.