Complaint Investigation Report

On 05/02/2021, R1 was seen at the John Muir Concord Medical Center for chief complaint of "back pain." R1 was diagnosed with a closed non displaced fracture of the greater trochanter of right femur. Thickening of the right gluteus maximus was noted, which suggested infiltrative hematoma. John Muir Concord Doctor believes the hip fracture and hematoma on the buttock are likely a result of a fall or similar type of trauma to the posterior.

On 05/27/2021, R1 was sent to John Muir Concord Medical Center after an unwitnessed fall in the bedroom. Staff 1 (S1) reported that after R1 was tucked into bed, S1 went to assist another resident. S1 heard a sound in R1’s room. S1 immediately responded and witnessed R1 was slouching on the floor and bleeding from the head. R1 was immediately sent to the hospital. R1 had a head scan which showed acute left subdural hematoma with a 4mm left to right midline shift.

On 05/28/2021, R1 was transferred to John Muir Walnut Creek Medical Center and was admitted to the Intensive Care Unit for a neurosurgery evaluation. Another head scan was conducted, and the subdural hematoma increased to 1.3 cm.

File review documents and staff interviews conclude that R1 was a fall risk resident. R1 was

unsteady while ambulating and sitting down. Fall mats and bed alarms were briefly used but were not successful and as such discontinued. Another fall prevention strategy was reminding R1 to use walker and reminding R1 to sit down. Staff stated that R1 required constant monitoring and supervision. R1 did not have one to one care.

Some of the staff reported that R1 would have benefited from one to one care. S2 stated that R1 was beyond a level of care that the facility could provide based on R1’s need for constant supervision.

R1 passed away prior to being interviewed. Death certificate lists his date of death as 06/05/2021 at 2210 hours. Immediate cause of death is listed as Traumatic Subdural Hematoma. Condition leading to the cause of death/underlying cause is Ground Level Fall.