Complaint Investigation Report

[CONTINUED FROM LIC 9099] Internal and external interviews and records unanimously established that on 08-02-2021, facility staff called 911 after C1 had a suspected seizure and fell in the bathroom. ER records confirm C1 had a “witnessed seizure,” and X-rays revealed C1 was diagnosed with a “right bimalleolar ankle fracture” with “diffuse soft tissue swelling.” C1 initially told ER staff, “Someone broke my ankle.” When asked to elaborate, C1 could only say, “The Dodgers broke my ankle last week when they were cheating.” Per their LIC602 Physician’s Report and SDRC records, C1 was developmentally and mentally disabled. Interviews of multiple facility staff and SDRC staff revealed C1 had a history of speaking about themselves in the third person, meaning C1’s use of “they” could be a reference to themselves.

According to interviews of facility Staff #1 (S1) and Staff #2 (S2): on 08-02-2021 around 10:50 PM, S1 was helping C1 to use the restroom. C1 was standing to urinate into the toilet bowl when they said aloud, “Oh boy,” and started to lose their balance and sway in the direction of the nearby shower. S1 tried to hold C1 up and yelled out for help. Staff #2 (S2) immediately went to the restroom and helped S1 slow/control C1’s fall to the shower floor, focusing on protecting the client’s head. According to staff and outside interviews, and corroborated by care records, C1 weighed close to 260 pounds at the time of the incident. S2 said during the controlled fall, C1’s leg got “stuck between the shower and the toilet.” The staff said C1’s lips were purple, their eyes rolled back in their head, and their body shook.

After a few minutes, C1’s symptoms fully subsided, and they returned to baseline alertness. C1 stated their desire to get up and finish urinating so staff helped them sit on the toilet seat, but they observed C1 could not put much weight on their right foot and said it hurt. When 911 personnel arrived, C1 was still seated on the toilet. S1 and S2 said they explained to paramedics that C1 was initially standing over the toilet, started a seizure, then had a controlled fall to the floor. However, 911 dispatch records only showed paramedics responding to a “[male] sitting on the toilet C/O right ankle pain.” According to hospital records, C1 “had a seizure while sitting on the toilet as per paramedic report.” In interviews, ER staff were under the impression C1 fell from the seat of the toilet to the bathroom floor.

Based on interviews and records, a preponderance of evidence does not exist to show that facility staff either physically abused or neglected C1, or caused their injury. The allegation is therefore unsubstantiated. An exit interview was conducted with Nyunah and Hollobaugh. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to Administrator Hollobaugh.