| Huntington Beach Fire Department EMS Personnel Medical Records dated 1/26/22 noted R1 was not alert and/or oriented and had what appeared to be old bruising around both eyes and nose. R1 also had redness around their neck and dried vomit around their mouth. EMS was unable to obtain a stroke neuro assessment due to R1’s mental status which staff noted was normal for R1. Upon arrival to the Emergency Room, R1 was believed to have had a possible stroke while in the ER. Radiology notes indicated no CT evidence of intracranial hemorrhage. Hoag Hospital Newport Beach Medical records from 1/26/2022 to 2/2/2022 revealed R1 sustained a dislocated right shoulder and fractured humerus and bruising to the face. Medical records indicated dark vomit is related to patient’s esophagitis. R1 underwent surgery while at the hospital to reset shoulder before returning to the facility.
Of the interviews conducted with staff, five of eight staff reported that fall risk residents are checked every hour while other residents are checked every 2 hours. Five of eight staff reported that before the unwitnessed fall, R1 was not a at fall risk; very mobile; and required little assistance. Staff also claimed that R1 had the same daily routine and was punctual for meals and ambulated with their walker with minimal assistance. Per review of Medical care notes dated from 11/6/21 to 1/18/22 R1’s physician made no observations of R1 to be a fall risk.
Although there were no logs to validate checks, interviews with staff revealed that R1 was checked on every 2 hours. Prior to being discovered on the floor at 6:50AM, staff reported R1 was last checked at 5:00 AM that same morning and appeared fine.
Interviews with R1’s responsible party reported that they visited R1 daily and felt comfortable with facility and staff. R1’s family had no concerns or fears about R1 returning to facility. Due to underlying medical diagnoses, R1 is unable to verbally communicate what happened.
Although R1 sustained a fracture while in care along with other injuries, the evidence does not support that fracture sustained was due to a result of neglect and/or lack of care and supervision. Therefore, based off information obtained and interviews conducted the allegations Resident sustained fracture while in care and Resident sustained injury while in care are deemed UNSUBSTANTIATED. Although the allegations may have happened or is valid there is no preponderance of evidence to prove the alleged violations did or did not occur.
An exit interview was conducted with Executive Director Sandra and Health Services Director and a copy of report along with LIC 811 confidential names list was provided.
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