complaint·May 17, 2024

When an overnight shift caregiver last checked on R1 at 0530 hours on 10/14/2022, she noted R1 was fine. A staff entered R1’s bedroom at 0600 hours to give her Ativan as a matter of course, not because of documented agitation, and it appears R1 was left in bed after the interaction. The majority of staff interviews conducted revealed that R1 was always checked first at the beginning of the morning shift (0600 hours) precisely because of being a fall risk. It is unclear why R1 would be left unattended in her bedroom after she was known to be awake. A morning shift staff documented that her first check was at 0630 hours, but based on an Internal Incident Report, this staff checked on R1 at 0700 hours, which is more consistent with her past checks but still within the facility’s safety check window of every two hours. Though R1 appears to have fallen in between staff rounds, sometime between 0600 and 0700 hours, her wandering behavior and attempts to get out of bed without assistance should have warranted attention. R1 was transported to the hospital and was diagnosed with a left hip fracture for which she underwent a left hemiarthroplasty. The allegation facility Neglect/Lack of Supervision resulted in R1’s fall is therefore Substantiated. In regards to the allegation: “Staff did not seek medical attention for resident in a timely manner.” It is alleged that R1 did not receive timely medical attention after suffering a fall and being in pain for several days. This allegation was investigated and completed by Investigator Santana with the Investigations Branch. Interviews conducted revealed that after R1 was found on her bedroom floor sometime between 0600-0700 hours on 10/14/2022, S3 assessed R1 and concluded she had not sustained injury, since there was no visible injury and R1 was able to take a few steps with her walker without complaining of any pain. S3 did not call 911 despite the fall having been unwitnessed because there was no apparent injury and R1 was on hospice, but S1-S2 conceded that the S3 should have called 911 even though R1 was on hospice because of uncertainty about whether R1 hit her head. S3 instead notified VITAS Hospice, likely at 0805 hours that same day, but a VITAS nurse did not arrive to assess R1 until 10/17/2022. Interviews, facility phone records, and VITAS records suggest the facility did not inform VITAS about R1’s change of condition despite calls from VITAS nurse on 10/15/2022 and 10/16/2022 to ask about R1. R1’s change of condition was evident based on facility staff member interviews and documentation, noting that after the fall, R1 was no longer attempting to get up from her wheelchair to bang on windows, which she had done as recently as the day prior. Additionally, R1 was noted as being sleepy and as sleeping the majority of the day on the three days following the fall. While the facility suggested this lethargy could have been attributed to Ativan, R1 had been taking the same amount of Ativan since 10/10/2022, when R1 was still agitated. A VITAS nurse assessed R1 on 10/17/2022 but did not get R1 out of bed. When a staff attempted to get R1 out of bed, at family member’s request, on the afternoon of 10/17/2022, R1 screamed out “in excruciating pain,” saying her back hurt. R1 was transported to the hospital on 10/17/2022 for congestion and left lower abdominal pain and was found to have a fractured left hip that was within two weeks old. R1 ultimately underwent a hip replacement. Had the facility called 911 on 10/14/2022, it is likely R1 could have been treated sooner. The allegation that facility Neglect/Lack of Supervision contributed to a delay in obtaining medical attention for R1 is therefore Substantiated. ***An immediate civil penalty will be issued today, in the amount of $500 due to neglect/lack of supervision which contributed to a delay in obtaining medical attention in which resident sustained a hip fracture. *** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report was provided to the Administrator along with the Appeals Rights.