Complaint Investigation Report

Staff sent hospice resident to hospital without authorization from POA or Hospice. - UNSUBSTANTIATED

It was reported that after two falls staff at the facility sent Resident 1 (R1) to the hospital for imaging and told the RP it was the facilities policy to send out the resident.

LPA reviewed an incident report dated 09/10/2025 which reports Resident 1 R1) complained of pain in left hip and shoulder following a fall. EMS evaluated R1 and transported to local hospital for further observation. Hospice was present and POA was notified. The facility planned to re-open R1 on hospice upon their return to the facility.

Hospice stated on 09/09/2025 R1 had a witnessed fall at 09:00 AM with no injuries and an unwitnessed fall at 04:30 PM during which R1 hit their head and there was a bruise. An hour after the last fall hospice visited R1 and noted resident was oriented and alert stating R1 didn’t seem to have a concussion but had a contusion on the left frontal region of their head. All extremities working fine required assistance ambulating. R1 had a bruise on their left hip. No pain noted. On 09/10/2025 hospice visited R1 to follow-up and things were totally different. Hospice discussed the two falls and spoke with facility staff who stated R1 was not doing well, was in pain and very cognitively different and totally out of baseline. Hospice informed RP who did not want R1 sent out. Facility staff stated they had to send R1 out to be examined at the hospital due to suffering a head strike during the fall. Hospice informed facility staff that they needed to call the RP and inform. Hospice stated they had no choice at that point and the facility sent R1 out to hospital.

LPA reviewed the admission summary for Oroville Hospital dated 09/10/2025 which states that the POA for R1 did not wish to have any further studies done. R1 was on comfort care and wanted R1 to return to the facility on comfort care. Facility staff requested R1 undergo hip x-rays to ensure there was no fracture. The hospital completed x-rays of both hips and found no fractures. R1 was returned to the facility on 09/11/2025.