complaint·May 6, 2024

CONTINUED FROM FORM LIC9099 Resident R1 is an 95-year-old resident who was admitted at the facility on March 3, 2022. Upon admission, R1 was stated to be ambulatory, requiring limited assistance with activities of daily living and administering her own medications. Following an increase in fall risk and fall incidents, R1 was reevaluated by their primary care provider and admitted on hospice care in October 2023. Additional preventative measures were implemented or offered by facility staff to address the resident’s fall risk, such as providing a commode toilet, removal of some furniture in order to make R1’s room more accessible and education on the use of the pendant and call system to request staff assistance. Postural supports were discussed but ruled out by R1 and their responsible party. R1’s medical assessment dated October 5, 2023 indicates a primary diagnosis of Coronary Arterial Disease with quadruple Cornonary Arterial Bypass as well as an indication of Mild Cognitive Impairment. Regarding the allegation that Due to neglect resident sustained multiple falls resulting in injuries, the following has been concluded: On January 1, 2024, R1 sustained a fall incident around 12:30pm and were found by facility caregiving staff on the floor of their unit’s bathrooms, as corroborated by interviews and staff notes reviewed. Resident was assessed after the fall and reported to pain or injury when assisted back up. No potential head injury was suspected. At approximately 1:30pm, R1 complained of pain and was provided with PRN pain medication. Later the same day, R1 received visits from their responsible party as well as from the hospice nurse. During the hospice assessment on that day, R1 “stood up very confidently on her own and seamed steady on her feet during [the] assessment. [R1] said she had mild pain and said she hurt a little bit. [Hospice nurse] said he assessed R1 from head to toe and said she was oriented; her pupils were alert and there were no visible injuries or bruising”. After the visits, at approximately 6:20pm, a loud noise was heard from the R1’s room. R1 was found unconscious and laying on the floor, with visible facial lacerations. A call to the paramedics was confirmed to have been initiated immediately and R1 was transported to UCI Hospital. R1 was admitted to the hospital with a diagnosis of subdural hematoma, blunt head trauma, subarachnoid hemorrhage, closed fracture of left side of maxilla and closed fracture of orbit. R1 is stated to have been unconscious upon admission. R1 was later discharged to a Vitas Hospice facility on January 3, 2024. R1 later passed away at the same facility on January 6, 2024. The death certificate was requested and obtained by the Department and indicated the primary cause of death as “coronary artery disease with contributing factors of chronic obstructive pulmonary disease”. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C R1 had an established history of fall risk. Facility followed the fall prevention plan and there were only two fall incidents requiring medical assistance verified to have been addressed by a call to paramedics and incident reports submitted to the Department. Based on the evidence gathered and interviews conducted during the investigation, there is insufficient evidence to corroborate the occurrence of neglect and/or lack of supervision on the part of the facility’s staff. The allegation listed above is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.