complaint·April 18, 2024

At 11:45 a.m. LPA Peraldi met with facility staff and explained the reason for the visit. Between 11:51 a.m. and 12:25 p.m. the LPA interviewed three (3) out of five (5) residents and one (1) staff. At 11:55 a.m., the LPA conducted a telephonic interview with the licensee/administrator. At 12:15pm the LPA obtained copies of pertinent documents. No immediate health and safety concerns were observed during the inspection. On 07/18/2023, from 3:12 p.m. to 5:57 p.m., Investigator Hector conducted interviews with R1’s resident representatives, staff, Simi Valley Police Department Detective, and the licensee/administrator; and on 08/29/2023, at 1:55 p.m., with the home health case manager. In addition, Investigator Hector reviewed Simi Valley Police Department (SVPD) report, Reliance Home Health report, and Los Robles Regional Medical Center report, Ventura County Medical Examiner Autopsy report, photos of R1’s injuries, and other facility file documents related to R1. The investigation revealed that R1 was a fall risk and had a history of falls. According to the medical records, R1 was transported via ambulance to the Los Robles Regional Medical Center and admitted on April 25, 2023, at 11:25 a.m. R1’s "reason for visit" diagnosis documented an unspecified intracranial injury. The admitting diagnosis included Dementia, Hypertension, and an "unwitnessed ground level fall." The chief complaint listed an unknown reason for fall, face injury, head injury, and loss of consciousness. The Electronic Patient Care Report confirmed "dispatch notified" occurred at 10:52 a.m. on April 25, 2023. The medical records stated R1 was found unresponsive at residential care facility. In addition, R1 had a "fall about 3 days prior with facial bruising but was not brought into the hospital at that time." Moreover, R1 had been, "having more frequent falls lately." R1 had a DNR/DNI with comfort measures only. The medical staff documented that R1 "did not regain consciousness" while at the emergency department. R1 was discharged to "Hospice" on April 26, 2023, early in the day before passing away on that same day. Per the Ventura County Medical Examiner Autopsy Report, the cause of death was listed as subdural hematoma due to blunt force head trauma. Contributing: Unspecified Dementia. Manner of Death: Accident. According to the SVPD report, R1’s resident representative reported that on 04/25/2023, at approximately 9:58am, R1’s other resident representative, received a phone call from facility Staff #1 (S1). S1 advised that R1 had slipped from their walker and fallen. (Continue to LIC9099c.) R1 suffered an injury to their lip as well as a bloody nose. At approximately 10:30am, R1’s resident representative was able to respond to the facility to check on R1, who was in bed. R1 was unconscious and unresponsive. 911 was called and R1 was transported to the hospital by ambulance. While at the hospital, it was discovered R1 was suffering from a brain bleed. R1 ultimately passed away on 4/26/2023 at approximately 8:30am while receiving treatment at the hospital. R1’s resident representative recalled seeing a pink towel in R1’s room that was saturated with blood. Furthermore, R1’s resident representative stated no one at the facility called 911 prior to R1’s resident representative asking staff to do so. No one was monitoring R1 after R1 had fallen and suffered a head injury. According to the Reliance Home Health Care Coordination report, S1 called the home health case manager to inform that R1 sustained a "witnessed fall" around 9:00 a.m. on April 25, 2023. S1 also reported that R1 had "nosebleeds which S1 was able to stop." The report confirms that "the clinician supervisor instructed S1 to call 911 emergency services immediately." The "Date and Time of Orders" was listed as "4/25/23 9:30 a.m." On the allegation “Questionable death”. R1 had an unwitnessed fall at the facility, was transported to the hospital, and died the next day from the injuries sustained from the fall. The medical records and coroner's report confirm that the cause of death was directly linked to the injuries suffered by R1 while at the facility. Moreover, R1 had a history of unwitnessed falls that the facility failed to address by increasing R1’s level of supervision. The Department found sufficient evidence to support the allegation of a lack of supervision resulted in the death of R1. Therefore, the allegation is deemed Substantiated at this time. On the allegation “Facility staff failed to seek medical attention for resident in a timely manner”. The investigation noted discrepancies related to the time of the fall and some staff statements were contradictory. All the information obtained during interviews revealed that there was a delay in staff initially responding to R1 who had taken a fall, there was no immediate call for emergency services, there was no call for emergency services after observing injuries related to R1’s head, and staff only called once R1’s resident representative arrived and observed the condition of R1. Moreover, the licensee/administrator and staff admitted that calling 911 was applicable only after a non-medically trained staff conducted an evaluation of a resident’s visible or non-visible injuries. The Department found sufficient evidence to support the allegation “Facility staff failed to seek medical attention for resident in a timely manner”. Therefore, the allegation is deemed Substantiated at this time. (Continue to LIC9099c.) On the allegation “Resident sustained unknown injury while in care”. The investigation noted that R1 had a history of unwitnessed falls that the facility failed to address by increasing R1’s level of supervision. R1 had a fall about 3 days prior to the 04/25/2023 fall incident with facial bruising but was not brought into the hospital at that time. The Department found sufficient evidence to support the allegation “Resident sustained unknown injury while in care”. Therefore, the allegation is deemed Substantiated at this time. On the allegation “Resident left the facility unassisted”. The investigation noted that R1 did leave the facility unassisted on 01/17/2023. R1 was left in the backyard unassisted, where R1 was able to walk out the side gate and wandered away from the facility undetected. Staff went looking for R1 and were unable to find R1. R1 was located by law enforcement and transferred to the hospital for evaluation. The Department found sufficient evidence to support the allegation “Resident left the facility unassisted”. Therefore, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Licensee/Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.