complaint·April 11, 2025

(Continue from LIC9099) Based on records review and interviews with relevant witnesses it was indicated that on December 14, 2023, there was an incident involving R1 and R2. At 6:15 a.m. during safety checks, staff observed R1 lying on the floor in R2’s room. Per staff interviews, there were no witnesses of the incident. Staff obtained immediate medical attention by emergency medical responder personnel for R1 who was transferred to the hospital via ambulance. A detailed review of R1 and R2’s medical records indicated that both residents were diagnosed with dementia and were under memory service care plans. In addition, both residents had a history of “sundowning” (confusion, anxiety, agitation, or aggression that can occur in the late afternoon or early evening) behavior. R1 was non-ambulatory and needed assistance to transfer in and out of bed. R1’s primary diagnosis was Parkinson’s disease; R1 did not have inappropriate or aggressive behavior but was confused/disoriented. R2 was ambulatory and able to independently transfer in and out of bed. R2’s medical records under “mental condition” the box for “Confused/Disoriented” was marked as “yes”. For inappropriate and aggressive behavior, the box was marked as “no”. In addition, both residents were in neighboring rooms, sharing a “Jack and Jill” adjoining bathroom. A review of the admission agreements and the pre-admission assessments for R1 and R2 indicated that they both were new residents (R1 was admitted on 11/18/2023 and R2 was admitted on 11/29/2023), to the facility with no history of aggressive or violent behavior. All the staff that worked on December 14, 2023, were interviewed on the date of the incident. The responsible parties of both residents were interviewed as well as an attempted interview with R2 was conducted on December 14, 2023. Due to R2’s documented dementia medical condition, they were not able to provide relevant details of the incident. Based on interviews with the assigned investigator with the County of San Diego Medical Examiner’s Office, the incident was ruled as “accidental” by the Medical Examiner’s Office. A review of relevant medical reports indicated that R1’s physician stated that R1’s cause of death was determined as blunt force trauma to their head. It was determined there were no witnesses to what, if anything, had occurred directly between residents R1 and R2, such as a physical altercation. According to interviews conducted with facility staff safety check protocols were adhered to during the shift when the event occurred. Safety check logs were obtained and reviewed which confirmed the required documentation of the safety checks. (Continue at LIC9099C) (Continue from LIC9099C) The Department has investigated the above-mentioned allegation and based on interviews with staff, residents, outside sources, and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Interim Executive Director, Nicole Long, to whom a copy of this report, LIC811 Confidential Name List, and the Licensee Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.