Complaint Investigation Report

Prior to admission into the facility, R1 had two hospital visits for concerns of head trauma. Hospital records for R1 indicated on 6/30/2022, a CT scan was completed due to concerns of head trauma, which was negative.

R1 was admitted to the hospital on 10/8/2022 and discharged 10/16/2022. R1’s CT scan and hospital records indicate “either ex vacuo subdural prominence or chronic thin bilateral subdural hematomas” and “no acute bleed.” The records indicate R1 will continue their Eliquis medication because there is a “low risk of bleed despite having a single fall.” Records also noted the hospital staff “discussed this with [R1’s family] that with [R1’s] history of multiple falls they should consider taking [R1] off Eliquis or discuss this with [R1’s] cardiologist.”

R1 moved into the facility in November 2022. R1’s physician’s report dated 11/7/2022 states R1’s primary diagnosis was “status post fall, L5 fracture, C1 fracture” with secondary diagnoses of dementia, atrial fibrillation, chronic embolism, thrombosis, and hypertension. R1 continued to take Eliquis. The physician’s report indicates R1 was confused/disoriented, able to follow instructions and communicate needs, and needed assistance with bathing, dressing/grooming, and toileting but was incontinent at times.

R1’s initial health and service evaluation (assessment) dated 11/10/2022 states R1 was a fall risk and had 3 falls during the 25 days they were at the Skilled Nursing Facility (SNF). R1’s Morse Fall Scale assessment indicated they were a level 3 out of 3 fall risk, and it states, “implement high risk fall prevention interventions.” Facility document “CA Health and Service Evaluation” document has handwritten notes on page 1 that state that “Stand by on off toilet” and “Standby dress” is noted. Handwritten notes also indicate “falls” and “3 in Valley Oaks,” the resident is on “(blood thinners), and “Eliquis free through program.” The assessment indicates R1 had limited mobility, decreased balance and “gait limited,” and R1 would be provided with stand-by assistance for transfers, toileting, bathing, and dressing. There is no signature of who signed the document. The Morse Fall Scale and Evaluation forms note that facility was aware of a recent history of falls and resident was on blood thinners prior to intake.

On 11/22/2022 at 2:46am, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall and was found lying on their right side on the floor outside their bathroom. No complaints of pain and no apparent injuries. R1 was reminded to use their pull cord. On 11/23/2022 at 5:48pm, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had a fall when care staff were dressing R1 after a shower. There were no signs of redness or bruising and no complaints of pain. On 11/26/2022 at 9:35am, the facility faxed a Physician Communication form to R1’s Primary Care Physician (PCP), indicating R1 had an unwitnessed fall with no complaints of pain and no signs of injury.