Complaint Investigation Report

The investigation revealed the following:

Regarding allegation: Staff did not seek client timely medical attention after sustaining a head injury at the facility.

It is alleged that on 09/29/23, staff failed to seek timely medical attention for C1 after C1 fell at C1's day program and hit C1's head against the refrigerator. Per interview conducted with C1, C1 confirmed to have fallen at day program and hitting C1’s head during the fall. Per C1, staff asked C1 if C1 was okay after the fall and helped C1 up. C1 was then told to stay seated for the remainder of the day and stayed at the day program until the end of the day. LPA asked C1 if medical attention or first aid was rendered, to which C1 stated nothing was offered or provided. Upon arriving home from day program, C1 notified CP of the incident occurred and CP took C1 to the hospital for further evaluation. Per interview conducted with CP, C1 called CP upon arriving home from day program and notified CP of the incident. CP stated to have been concerned after C1 told CP to have felt "tired" after learning C1 had a fall with a head injury at the day program. CP stated that the hospital attending physician diagnosed C1 with traumatic hemorrhaging of the brain due to the fall C1 had. Per the Medical Visit Information review, it was discovered that the attending physician noted C1 diagnosed with Traumatic Brain Hemorrhage. Per interviews with S1-S3, (3) of (3) staff admitted to C1 falling and hitting C1’s head. S1 and S2 stated that following the fall, C1 was checked for visible injuries by S1 and S2 and was observed for any changes in condition that would indicate C1’s injuries were severe. C1 was not sent home early and per S1, an ice pack was given to C1. (2) of (3) staff were unaware if medical attention or first aid was rendered or offered by other staff to C1. (3) of (3) staff could not answer what the policy or protocol is following a head injury of a client, other than observation for visible injury and/or symptoms of severe injuries. After review of C1’s Physician’s Report and current IPP, it was noted that C1 is ambulatory, does not have any history of falls, and is not deemed a fall risk. It was noted that the day program filed an incident report timely to the licensing department, and C1’s placement agency, as well as calling the licensing department to report the incident, on 09/29/23. Per the incident reports obtained, the incident occurred on 09/28/23. (2) of (3) clients interviewed could not corroborate the allegation.

Based on LPA's observations, records review, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is Substantiated.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

Exit interview was conducted and a copy of the report and appeal rights were provided.