Complaint Investigation Report

Allegation: Resident sustained a broken arm while in care

The Department found that on 10/10/2024, at or around 0555 hours, S1 found R1 on the floor of R1’s kitchenette when conducting an incontinence check. R1 reported that they had gotten up to get something to drink on their own. R1 did not press their pendant to request staff’s help. S1 called the overnight supervisor S2, who responded and assessed R1. R1 complained of pain and injury to their head and left arm. R1 was transported to John Muir Medical Center via ambulance. While in the ambulance, R1 reported that they stood up to try to get a pill and fell landing on their left shoulder and face and was unable to get up. R1 was also found to have a Urinary Tract Infection (UTI). R1 underwent a Computed Tomography (CT) scan, which showed a fracture of the left humeral head, neck, and proximal diaphysis. R1’s face was also bruised on the left side as well as their left shoulder.

R1’s responsible party is aware of at least six falls and said most of R1’s falls were due to a history of UTIs. R1 has a wrist pendant that they can press to alert and request staff’s assistance. W1 stated that there are no real fall prevention methods in place for R1 other than frequent checks, escort assistance, and the wrist pendant. Staff interviewed vaguely recalled details of R1’s fall from 10/10/2024, but stated R1 got up on their own and did not press their pendant button to ask staff for help, despite being bed bound and unable to stand up or walk on their own. S2 said a family conference would be held and a resident’s care plan would be amended to add additional services when a resident falls more than three times within a 30-day period.