Complaint Investigation Report

In addition, on 3/3/2020 R1 was left unsupervised without the 1:1 private caregiver, nor the alarm floor mat used to prevent falls. IB’ investigation revealed the following:

Per IB’s record review: Per A dmission agreement: R1 was admitted to facility 11/23/2019. Per Physician Report dated 11/22/2019 R1 primary diagnosis is Dementia “supervision/ assistance needed” Secondary diagnosis is Frailty: “assistance is needed in walking and transfers and supervision to avoid falls.” Resident is able to transfer to and from bed independently; it is noted that: “needs supervision/ reminders for walker use- to be accompanied by helper, high fall risk.” Per Torrance Memorial Medical Center records: On 1/11/2020 R1 arrived at Torrance Memorial Medical Center (TMMC) at 1717 hours due to a fall and a laceration to the face. A CT scan was done on 1/11/2020 2028 hours which revealed a close heady injury with a small amount of hemorrhage. On 3/4/2020- a CT of the brain/ head without contrast was conducted and it showed a “large left subdural hematoma…”. A consultation states the head CT showed slight increase in Subdural Hematoma.

-Per IB interviews: R1 sustained a serious injury from falling, resulting in hospitalization. R1 had arrangements for a one-on-one caregiver from 5:30pm - 1:00am due to resident was a known fall risk. During the evening, on 3/3/2020 R1 was left without adequate supervision. The facility could not find someone to cover the shift and the wellness center staff failed to notify R1’s responsible party. The floor caregiver sat R1 in a recliner inside residents’ bedroom without using available alarm floor mat. R1 got out of the recliner and fell. R1 was down on the floor for an unknown amount of time. R1 was not immediately sent out to the hospital, even though resident had a history of subdural hematoma from a fall suffered on 1/11/2020. LA county fire was dispatched on 3/3/2020 at 2238 hours to Belmont due to a complaint of back pain. On 3/3/2020, according to the medical records; R1 was diagnosed with worsening subdural hematoma likely exacerbated by the fall. Resident had to undergo a craniotomy procedure to evacuate the subdural hematoma.

-Per IB Interviews: Resident sustained unexplained injury: On the evening of 3/3/2020 R1 suffered a fall in which the resident was not sent to the hospital. Later that evening R1 fell a second time while a caregiver was assisting resident into wheelchair. R1 sustained an injury to the lower back which resulted in a welt. Facility documentation does show that R1 sustained a skin tear to left forearm and a small bruise on the back. Facility failed to notify residents responsible party about the second fall and unexplained injury to the