complaint·April 29, 2025

LPA reviewed three (3) unsigned Unusual Incident/Injury Reports (UI/IRs) regarding R1. The UI/IRs have a date on the bottom left corner stating “5/1/2023” and note the following. On 1/25/2023, R1 had a witnessed fall in the activity room. R1 was assessed, did not have any visible injuries, hit their head, or complain of pain. R1’s “R/P” and “PCP” were notified. The “Medical Treatment Necessary?” section is marked “No”. On 3/30/2023, R1 reported they felt dizzy which caused them to lose their balance and fall onto their buttocks. R1 was assessed for injuries and was observed with redness to their lower back. There were no other visible injuries or complaints of pain. R1’s “PCP” and family were notified. The “Medical Treatment Necessary?” section is marked “No”. On 4/7/2023, R1 reported on 4/5/2023 they fell in the restroom after losing their balance. R1 was assessed for injuries and reported mild left inner thigh pain. R1 denied hitting their head and staff did not see any visible injuries. R1’s “PCP” and family were notified. Family has since taken resident to urgent care for an x-ray and no fractures were found. The “Medical Treatment Necessary?” section is marked “No” and states “Resident was evaluated in urgent care”. A review of the facility’s Narrative Charting noted the following. On 1/25/2023 at approximately 7:30 p.m., R1 was sitting in a chair in the activity room and fell to their knees while attempting to stand up. R1 was able to get up by themselves and the fall was witnessed by staff. R1 did not hit their head, have any visible injuries, complain of pain, and the responsible person was notified. R1’s service plan will be reviewed/updated and “f/u with PCP”. On 3/30/2023 at approximately 7:00 a.m., R1 reported feeling dizzy earlier in the morning which caused them to lose their balance, hit their back on their dresser, and fall onto their buttocks. R1 denied hitting their head or having any pain. Staff assessed R1 for injuries and observed redness to R1’s lower back. Family was also notified. R1’s service plan will be reviewed/updated and “f/u with PCP”. On 4/7/2023 at approximately 7:00 a.m., R1 reported falling on 4/5/2023 at around 5:00 a.m., while attempting to get onto the toilet. R1 complained of mild pain to their inner left thigh. R1 denied hitting their head and staff did not see any visible injuries. Family has since taken resident to urgent care and no fractures were found. R1’s service plan will be reviewed/updated, “f/u with PCP”, and “PT/HH requested for recent falls”. Regarding the allegation, “Neglect/Lack of Supervision resulting in resident sustaining injuries” it was alleged R1 sustained fractures from experiencing unwitnessed falls in the facility. Staff 1 (S1) was interviewed and reported the following information. R1 had two (2) unwitnessed and one (1) witnessed fall while residing in the facility. During the unwitnessed falls, R1 was able to get up by themselves and did not notify staff until later during the day. R1 was assessed and did not have any visible injuries or change of condition and did not complain of severe pain, only soreness. Staff checked on R1 every two (2) hours due to R1 being a fall risk. On 4/7/2023, R1 complained of pain and the facility gave R1’s family the option to transport R1 to urgent care or have staff send R1 out. R1’s family chose to transport R1 to urgent care. R1’s family reported R1 received x-rays, but nothing was found and R1 returned to the facility with no medication orders. R1 was referred to physical therapy due to their recent falls. R1 was reportedly taken to urgent care on 4/7/2023 after experiencing a fall in the facility. A review of R1’s medical records from Accelerated Urgent Care indicated R1 complained of bilateral hip pain and had been falling at approximately 4:00 a.m., while getting to the bathroom. The urgent care medical records stated, “There is no evidence for acute fracture. However, please note that in elderly patients a fracture may be occult and difficult to exclude with certainty by X-ray evaluation. To exclude an underlying subtle or occult fracture with certainty further evaluation with MRI is recommended.” A review of R1’s medical records from Loma Linda University Medical Center Murrieta noted on 4/21/2023, R1 was taken to the emergency room due to leg pain and having an unwitnessed fall on 4/5/2023. Medical records note R1 was taken to urgent care on 4/7/2023 and received back and hip X-rays and no abnormalities were noted. Medical records also note R1 received a CT scan of the left hip which showed fracture of superior and inferior pubic ramus as well as compression fracture of L5 vertebrae which appeared consistent with the cause of R1’s reported pain. Regarding the allegation, “Staff failed to seek timely medical attention after resident's fall” it was alleged the facility neglected to seek medical attention for R1 after the falls. An interview with two (2) additional staff was conducted who reported it is the facility’s protocol to activate emergency medical services when the facility learns a resident experienced an unwitnessed fall in the facility. However, LPA reviewed the facility’s program outline, and the “Medical Emergency” section notes the following. It is the facility’s policy to summon emergency medical services when a resident exhibits signs and systems of distress and/or emergency condition including a fall with deformity, severe pain or head injury. Non-emergency transport is only used when the resident needs urgent but non-emergency medical care, such as stitches, controlled bleeding, etc. The Resident Care Director or medication technician on duty is to contact the resident’s family/responsible person as quickly as possible, once the resident is safely under the care of the paramedics. Additionally, the UI/IRs and Narrative Chartings documented R1 was assessed, did not complain of severe pain, head injury, or sustained a fall with deformity. One (1) of three (3) staff interviews conducted reported residents were checked on at least every hour during the nocturnal shift and additionally, as needed, if staff heard any unusual noises. One (1) of three (3) staff interviews conducted reported R1 constantly walked around in the facility and remained in their line of sight during day hours. R1 was interviewed and reported staff were always around. R1 was unable to recall if staff checked on them throughout the day. R1 reported they informed staff they were “fine” and requested staff leave them alone. LPA also made several unsuccessful attempts to conduct an interview with four (4) additional staff reportedly present during the alleged incident time-frames. The Department did not receive an additional care plan outlining a focus to prevent/reduce the risk of R1 falling. Regarding the allegation “Staff failed to notify authorized representative of resident’s fall” it was alleged the facility did not notify R1’s responsible person of two (2) of R1’s falls. The UI/IRs and Narrative Chartings documented R1’s “R/P”/family were notified after the falls. However, a witness interview was conducted with one (1) of R1’s healthcare POA agents who identified themselves as the main point of contact between R1’s family/POA agents and facility staff. The witness reported the facility informed them about the 1/25/2023 fall R1 experienced in the facility. The witness added R1 called them from their cellphone and informed them they experienced a second fall in the facility on approximately 3/30/2023. The witness does not know if R1 reported the second fall to facility staff. The witness reported they notified facility staff of R1’s second fall. The witness also reported R1’s family member visited R1 in the facility in April 2023 and informed facility staff they believed R1 required a medical evaluation due to having leg pain. The witness reported facility staff called them to notify them of the new information received. The witness reported on approximately 4/12/2023, R1 was removed from the facility and in the care of their family and taken to the hospital for further evaluation on 4/21/2023. During S1’s interview, they also confirmed R1 was removed from the facility on 4/12/2023 and in the care of their family. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this entire report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Leth.