Complaint Investigation Report

Resident R1 was admitted to the facility on September 30, 2013 with a primary diagnosis of hypertension and no initial indication of major neurocognitive disorders at the time of admission. R1 was discharged from the facility on January 9, 2024.

Regarding the allegation that Staff neglect resulted in a resident sustaining an injury from multiple falls: Based on the evidence gathered, there have been multiple instances of fall incidents sustained by R1, at least one of which resulted in injury and hospital treatment. The evidence gathered is however insufficient to clearly establish that the falls were attributable to staff neglect rather than to changes in the resident’s condition. The allegation is therefore found to be Unsubstantiated.

Regarding the allegation that Staff left a resident unattended while being transported to the hospital, the following has been concluded: After a fall sustained on December 8, 2023, R1 was first transported via EMS to Hoag Hospital in Irvine before being transferred to Hoag Hospital Newport Beach at the neurosurgery department due to a suspicion of a subdural hematoma. A review of the resident records maintained at the facility also allowed LPA to corroborate that the responsible party for the resident had been contacted by the facility staff following the fall. A fax reporting the fall to the resident's physician was also located. Report states that EMS had initially informed the facility that the resident would be transported to Saddleback MemorialCare but was re-routed to Hoag Irvine for unknown reasons which appears to explain why R1’s responsible party had to actively attempt to locate the resident following admission. A copy of R1’s Consent for Emergency Medical Treatment was present and on file.

As resident was placed under the responsibility of EMS personnel, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.