Complaint Investigation Report

On 1/21/2022, (R1) was admitted to the facility late afternoon and was accompanied by his family with no reported incident documented by staff for that day. On 1/22/2022, at about 0515 hours, overnight staff found (R1) on his side next to the bed. Med Tech 1 (MT1) assessed (R1) for injury and reported “None found.”(R1) was not able to report how he fell. On 1/22/2022, at about 0700, (R1) had another unwitnessed fall in the hallway in front of his bedroom door and was found by Med Tech 2 (MT2) who assessed (R1) and reported on incident report that (R1) sustained an abrasion on his nose, forehead and left elbow. Interviews concluded that (R1) complained of discomfort and pain upon applying any pressure to his injuries to (MT2). Review of documentation concluded that (MT2’s) report and assessment was signed off by Health Service Director (HSD) Richard Mariona, Licensed Vocational Nurse on 1/24/2022 who was not present at the facility during any (R1’s) falls. There was no further document indicating follow up or additional assessment.

On 1/23/2022, at about 1415 hours, (R1) had a third unwitnessed fall and was found by Caregiver 1 (CG1), who assessed (R1) and reported to have no injuries and no discomfort and was instructed by (HSD) Richard Mariona via telephone to check on (R1) every 30 minutes or so for any change in condition.

On 1/24/2022, at about 0900 hours Caregiver 2 (CG2) was conducting routine rounds, and checked (R1) due to numerous reported falls. Interview with interviewee concluded that (R1) was unable to get up from bed and was complaining of pain on his right side. (R1’s) Family was contacted and asked if they wanted to come and pick up (R1) and transport him to the hospital. (R1’s) Family indicated “If you can’t move him out of bed how could I?” Facility called paramedics and (R1) was taken to Fountain Valley Hospital around 1100. (R1’s) Family arrived to the facility prior to (R1) being transported to Fountain Valley Hospital and took pictures of (R1’s) injuries. (R1) was examined by attending physician Dr. David Hamilton who diagnosed (R1) with fractured ribs from the fifth to the eight rib on the left side, weakness, head injury and a Pneumonia. (R1) was Admitted into Fountain Valley Hospital on 1/25/2022, and was discharged on 2/2/2022. Upon discharge, (R1) returned to reside with Family.