Complaint Investigation Report

There was no involvement from the San Diego County Medical Examiner’s office in this case.

Per Licensee’s “Fall Management Protocol” written policy, all falls, witnessed or unwitnessed, require several response steps to include that “any resident sustaining a fall will also be placed on Alert charting status” and that “the [resident's] healthcare practitioner will be notified using Form 213a, Physician Fax Report of Fall.” As confirmed in administrator interview, Licensee defined “Alert charting” as the facility’s licensed nurse meeting with the resident face-to-face daily, for at least three (3) consecutive days after the fall, to assess the resident’s health and ask about their experienced symptoms, and to document these findings in electronic progress notes. During their 06/02/2025 site visit, LPA Nguyen requested from Licensee copies of the facility staff’s charting and/or progress notes, which would evidence that “Alert charting” was performed on R1 post-fall. However, facility managers replied that no such notes existed which could prove that R1 was placed on “Alert charting status,” as was required by Licensee’s own written policy.

While the available evidence cannot prove that R1’s blood pressure was elevated during or shortly after their fall on 03/22/2025, or that staff had constructive knowledge of R1’s rising blood pressure, the facility plan of operation, and interviews with facility staff corroborate that the proper protocol was to have R1 medically assessed and continuously observed by competent medical authority after their fall.

While there was not enough evidence to show that that the facility was ultimately responsible for R1’s death, [See related LIC 9099 for complaint control number 08-AS-20250530085015], there is a preponderance of evidence to show that R1 experienced a serious medical emergency for which they did not receive timely medical care. Therefore, the complaint is substantiated and deficiencies cited [see attached LIC 9099(d)]. The licensee is hereby notified that additional civil penalties are under review by the Department’s legal division per Health and Safety Code § 1569.49(f).

An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.