A review of R1’s physician’s report, dated 02/26/2019, indicated R1’s primary diagnosis as severe traumatic brain injury, and secondary diagnosis as epilepsy/seizure(s). The report indicated R1 was frequently confused, occasionally was able to follow instructions, able to communicate poorly, was not able to transfer to and from bed independently and was identified as bedridden.

Information obtained revealed that on 08/17/2023, R1 was taken to the emergency room. A review of R1’s Community Memorial Hospital-Ventura Discharge Instructions, dated 08/17/2023, revealed that R1 was seen at the emergency department and diagnosed with urinary retention.

Staff interviews revealed that R1 had a history of leg cramps, urinary track infections, had a condom catheter, and would make grunting noises when experiencing leg cramps or when urinating. Four (4) out of five (5) care giving staff that worked during the days (from 8/14/23-8/16/23), leading to R1’s emergency room visit on 08/17/2023 revealed that they did not observe any unusual signs in R1 that lead them to believe that R1 needed immediate medical attention. Staff revealed that R1 was observed to be experiencing cramping more than usual during these days, however, staff believed it was “normal” as R1 had a history of cramping, experienced similar symptoms in the past, and usually it would resolve by the next day. In addition, staff revealed that the mannerisms that R1 was displaying were the same as R1’s usual cramps, R1 did not verbalize any pain, and they were notifying the administrators and charting their observations.

Assistant Administrator #1 (AA1) revealed that on 08/15/2023 they were at the facility, and they were informed that R1 was grunting more than usual and that R1 had also reported pain to staff. AA1 proceeded to assess R1, and did not observe R1 in any pain, checked R1’s urine bag to see if it looked abnormal, and asked R1 if they had any pain to which R1 replied, “no”. AA1 also revealed that they contacted R1’s Urologist that same day to advised them of R1's symptoms and get medical advice/suggestion if an emergency room visit was warranted. However, AA1 was not able get a hold of R1’s Urologist. Assistant Administrator #2 (AA2) revealed that staff never voiced concerns to them of R1 being in pain, they observed R1 cramping more than usual between 08/14/2023 and 08/16/2023 however, they believed it was part of R1’s usual cramps, and did not observe anything that made them believe R1 needed immediate medical attention. Report will continue on LIC9099-C, 3rd page.

On the allegation “Facility failed to obtain timely medical attention for client” Information obtained from the interviews conducted revealed R1 had a history of cramping, UTIs and grunting and majority of the staff did not observed anything unusual in R1 that warranted immediate medical attention. Furthermore, Assistant Administrator #1 attempted to reach R1’s doctor on 08/15/23 when concerns were initially voiced, R1 had a telehealth visit on either 08/15/2023 or 08/16/2023, and R1 was sent to the Emergency Room on 08/17/2024 when symptoms reached a level that needed medical attention, therefore the above allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report Provided.