Complaint Investigation Report, 04/08/2025 — Ponte Palmero, Cameron Park CA

Records were reviewed regarding the death of R1. On June 18, 2024, at about 0144 hours, R1 was admitted to the emergency department due to a recent unwitnessed fall and sustained a head injury with a hematoma on their left ear. R1 was found on the ground between approximately 0100 hours and was last seen by Ponte Palmero staff in bed at 2300 hours. R1 was admitted to the hospital due to the blunt/critical trauma level II and diagnosed with a subdural hematoma, hematoma of the left ear, and falls. Due to the severity of R1’s injuries, R1 was place on comfort care. On June 29, 2024, R1 passed away. Certificate of Death indicated that R1 died from cardiac arrest and a traumatic brain injury with a subdural hematoma. R1’s facility file documents, Physician’s Report, Resident Assessment, Resident Charting Notes, Incident Reports, and Needs and Services plans, revealed that R1 was documented as being a fall risk, using a walker to ambulate, and having unsteady gait. R1 was admitted to Ponte Palmero Memory Care Unit on August 23, 2022. Records indicated R1 fell (7) seven times on 10/2/2023, 11/29/2023, 1/31/2024, 3/30/2024, 4/29/2024, 5/3/2024, and 6/18/2024. R1 only had two Resident Assessment’s dated August 18, 2023, and September 30, 2023, that indicated R1 needed more standby assistance. R1 did not receive any additional care services, such as an alarm mat, to prevent them from falling. Memory Care Director, Dej’ja Bracy stated that R1 was not considered a fall risk and did not need a fall prevention plan. Former staff mentioned R1 was independent, however could be considered a fall risk and noticed a change in R1’s ability to walk or to get out of bed. Based on department record review and interviews conducted, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $500 is assessed.