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32 | CONTINUED FROM FORM LIC9099
Resident R1 was admitted to Los Alamitos Medical Center for a fall sustained on December 8, 2023 for which paramedics were called. R1 sustained a hip fracture and was operated to treat the fracture, then discharged back to the community on December 12, 2023. R1 eventually passed away on December 14, 2023. The death report submitted by the facility to the Department states the cause of death as "Multip[le] System[ic] Failure due to symptoms related to end stage Alzheimer's dementia". Records reviewed showed that R1 had been identified by facility staff to constitute an increased fall risk as early as October 10, 2020 and had notified the family accordingly upon admission. Evidence of an adjustment in medication show that R1's Xanax dosage had been increased by the hospice physician on December 1, 2023 stating "frequency increased due to increased restlessness. Ordered by Dr. Dayrit and consent to by [daughter]". Orders from the same date indicate that facility staff was authorized to use "tab alarm in bed and wheelchair to alert staff of unassisted transfers" and "may keep bed low with floor mattress", indicating both an awareness of the fall risk and measures taken to address it. LPA was additionally able to review hospice admission notes dated August 9, 2023 stating that R1 was "Declining, not eating with weight loss, episodes of [shortness of breath] and low heart rate". Visit notes from the attending hospice nurse dated November 30, 2023 also mention a fall incident with no injury and indicates that the prescription adjustment had been requested directly within hospice staff with no mention of facility staff. Hospice notes following the readmission on December 12, 2023 confirm that the death was pronounced by the hospice physician and details extensive comfort measures taken during that time.
Regarding the allegations that Lack of supervision resulting in resident sustaining multiple falls and Lack of supervision of resident resulting in a hip fracture, the following has been concluded: Based on records reviewed, it was determined that both the fall risk at baseline and the elevation of R1's fall risk due to R1's declining condition had been assessed and were being addressed through vigilance measures by facility staff with the assistance of the attending hospice professionals. Therefore the allegations are found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred.
An exit interview was conducted and a copy of this report was provided to a facility representative. |