Complaint Investigation Report

Allegation #1: Resident (R1) sustained a fracture due to a lack of care from staff.

It is alleged that Resident (R1) fell and sustained a vertebral fracture injury due to falling from R1’s wheelchair.

This investigation revealed that R1 was admitted to Vista Del Mar Senior Living on 03/03/24. A record review of R1’s Physician Report (dated: 03/15/24) revealed that R1 is non-ambulatory and requires staff assistance to transfer to and from bed. On 4/22/25, staff found R1 sitting on the floor in R1’s room. Staff observed R1’s forehead was bleeding, and an abrasion under the left eye. Staff reported R1 experienced an unwitnessed fall and called 911. R1 was transported to Memorial Care Long Beach Medical Center, where an imaging test was performed. The department conducted a review of Memorial Care of Long Beach's medical records and found that the imaging test results detected R1 sustained a cervical spine fracture and soft tissue swelling. The department conducted a record review of the facility’s notes and found that R1 experienced unwitnessed falls from R1’s wheelchair in R1’s room on 03/25/24, 3/26/24, and 3/28/24. The department conducted a review of the facility notes and found that R1 did not prefer to sleep in a bed and would sleep in R1’s wheelchair. The department conducted interviews with S1-S4 and found that staff were aware that R1 would fall asleep in R1’s wheelchair, fall forward, and fall from the wheelchair.