Complaint Investigation Report

Allegation: Resident sustained a fracture due to lack of care from staff

On 12/09/2023 at approximately 0700 AM staff (S1) heard resident (R1) shouting for help, and S1 came to R1’s aid. S1 found R1 sitting on the floor, complaining of back pain while holding onto his hip. S1 did not observe any visible injuries on R1. S1 offered to call 911, but R1 declined and requested assistance to stand. S1 helped R1 back to bed and resumed his duties.

Allegation: Staff did not seek medical care for resident in a timely manner

Review of R1’s medical documents, from Kaiser Permanente at Walnut Creek revealed on 12/09/23 at approximately 0330 a.m., R1 sustained an unwitnessed fall. During the night shift, S1 reported the fall to the oncoming day shift caregiver, S2, at approximately 0700 a.m. At approximately 0900 a.m., S2 informed the in-house Registered Nurse (S3) of the incident.

S3 provided instructions to S2 over the phone to assess R1. S2 documented no visible marks, bruises, skin tears, or discoloration, but noted that R1 moaned in pain when moved. S3 did not instruct S2 to call 911, nor did S3 advise any additional assessment. The direction provided was to administer pain medication, monitor R1 for one hour, and, if R1’s family did not respond within two hours, arrange transport to the hospital.