Complaint Investigation Report

documented R1 a fall risk who required the use of a walker to assist with ambulation or use of a wheelchair. Facility records documented R1’s diagnosis of Alzheimer's Dementia and multiple other co-morbidities. Review of hospital medical records page 7 indicated R1 was admitted to the Emergency Department on April 11, 2022, with diagnoses of “Nontraumatic Intracerebral Hemorrhage unspecified, Traumatic Subarachnoid Hemorrhage without loss of consciousness, Fracture of Vault of Skull, initial encounter for closed fracture, and Dependence on wheelchair.” Page 18 of the hospital medical records documented a Clinical Impression of “Cerebral Hemorrhage, traumatic-including cerebral contusions, brainstem hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage.” R1 died at the hospital on April 13, 2022. A copy of R1’s Death Certificate documented the cause of death as Traumatic Intracranial Hemorrhage due to Complications of a Ground Level Fall.

Regarding the allegation: The facility failed to provide care and supervision to resident resulting in death the investigation revealed the following. R1 was admitted to the Memory Care unit of Pacifica Senior Living South Coast on February 1, 2022. R1 had a history of falls and previously sustained a pelvic fracture. On April 10, 2022, at approximately 7:15 PM, R1 sustained an unwitnessed fall in their room. Staff 7(S7) was the first Caregiver who found R1 lying on the floor and notified Staff 5 (S5) of R1’s unwitnessed fall. Upon entering R1’s room S5 who was working as a Medication Technician observed R1 lying on the floor in a supine position with R1 holding their head with their right hand. S5 documented R1’s position by taking a picture and then notifying R1’s responsible party via text of R1’s fall. S5 also stated they notified Staff 1 (S1) of R1’s fall. S5 stated they assessed R1 for injury and pain, but no pain was reported by R1. S5 with the assistance of Staff 10 (S10) helped R1 from the floor onto their bed. S5 indicated they assessed R1 by asking R1 if they had hit their head and R1 replied “no”. S5 was questioned regarding the Internal Incident Report they completed on April 10, 2022, where S5 failed to document the position R1 was found in as well as why S5 did not immediately call 911 following R1’s unwitnessed fall. S5 stated they relied on what the resident was reporting and the family to make the decision for medical treatment. S1 stated R1 was observed more frequently throughout the night, but no written record was documented regarding how often R1 was checked and what type of assessment was conducted. S1 could not provide a response when asked why 911 was not called when S1 received a photo of R1 lying on the floor holding their head. S1 stated R1 “appeared to be okay with no visible injury.” The last time S5 checked on R1 was at the end of their shift at approximately 10:30 PM and per S5, R1 was watching a movie. On April 11, 2022, Staff 8 (S8) a Caregiver observed R1 had a change of condition and appeared more confused but S8 did not request anyone to assess R1. When