complaint·April 15, 2024

On August 21, 2023, R1 was hospitalized at 9:58 AM per hospital admission records due to severe right leg pain. Hospital admission records reviewed note R1 reported right thigh pain with swelling for one week. R1 was determined to have a Periprosthetic fracture around their internal prosthetic right hip joint. Per a behavioral assessment report dated April 1,2023, R1 is wheelchair bound and is at risk for falls due to refusing staff assistance and trying to get up from their wheelchair or maneuver their wheelchair without supervision. The assessment notes R1 is very unsteady on their feet when they are bearing weight on their legs and can only stand briefly with staff assistance. There are times when R1 needs two staff assist for transfers due to being uncooperative. R1 is reported to have multilevel disc degeneration in their back and neck. Additionally, R1 has hip pain and osteoarthritis in their leg and previously under went a hip replacement surgery. During an interview with R1’s Regional Center of Orange County Service Coordinator (SC), it was noted a serious incident report (SIR) was submitted dated August 21, 2023, in which the facility reported R1 had reported having leg pain as early as August 18, 2023. When interviewed, the Licensee stated they had written the wrong date on the report and stated they became aware of R1’s pain on August 21, 2023 when staff brought it to her attention. Per interview conducted with Staff 1 (S1), R1 began expressing pain on August 20, 2023, while assisting them in the shower. S1 administered over the counter Tylenol and placed R1 in their wheelchair. S1 described R1 okay and as good. The following day, S1 reported assisting R1 with another shower. During the shower R1 did not express any pain or discomfort. S1 stated it was not until R1 was brought to the breakfast table that Staff 2 (S2) noticed swelling on R1’s thigh. S2 took a photograph of R1’s thigh and sent it to the facility Administrator informing them R1 needed to go to the hospital. S2 drove R1 to the hospital themselves and was later met there by the Licensee. An interview was attempted with R1, but unable to complete due to cognitive barriers. Therefore, based on interviews conducted and documents reviewed, the allegation that Facility failed to seek timely medical treatment is deemed Unfounded, meaning the allegation was false, could not have happen or is without reasonable basis. We therefore dismissed the complaint. An exit interview was conducted, and a copy of this report and confidential names list was provided at the facility.