complaint·April 30, 2021

The Department reviewed medical records, which indicate that on 01/16/2020 R1 was taken to the hospital for a fall and was admitted. R1 was diagnosed with a hemorrhagic stroke. Based on interviews with facility and hospital staff and review of records, the Department determines that the above allegation is substantiated, meaning that there is a preponderance of evidence to prove the allegation did occur. An immediate civil penalty of $500.00 is being assessed against the facility today for a violation resulting in serious bodily injury to a resident in care. Additional Civil Penalties may be assessed for serious bodily injuries. Deficiencies were cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 9099-D. Report was discussed with Executive Director Rhonda Bekkedahl. A copy of this report and licensee’s Appeal Rights forms given to Executive Director. This report will be sent to Executive Director Rhonda Bekkedahl so that it can be signed and returned to CCL. Interviews with facility staff indicate that on 01/16/2020, staff S1 checked on R1 in R1’s room at 7:00 AM and then proceeded to check on the resident in the adjacent room. While checking on the next resident, S1 heard a thump sound in S1’s room. S1 returned to R1’s room and found R1 to be on the floor snoring. S1 called for assistance from S2. S2 conducted a check on R1, who did not complain of pain and exhibited good vital signs. The only observed injury was redness on the side of R1’s head, to which staff applied ice. S2 and S3 continued to conduct neuro checks on R1 every 15 to 30 minutes throughout the day and recorded normal results for R1. At 8:50 AM, R1 vomited. At 9:30 AM, R1 vomited a second time and in response, S2 attempted to contact R1’s physician, who was not able to be contacted. S2 then requested advice from the on-call doctor, who requested a fax regarding R1’s condition. S2 then contacted R1’s daughter about R1’s fall and present condition, and R1’s daughter agreed to postpone sending R1 to the emergency room since R1’s vital signs were normal. The on-call doctor stated during interview with the Department to have not been able to determine if R1’s death would have been avoided if facility staff brought R1 to the hospital immediately after the fall. The Department review of R1’s care plan indicates that the facility followed the care plan to reduce the risk of R1 falling. Based on interviews with facility and hospital staff and review of records, the Department finds the above allegation to be unsubstantiated, meaning that although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.