The resident, who had diagnoses including anoxic brain damage, diffuse traumatic brain injury, and epilepsy, was found on the floor next to his bed at Healthcare Center of Orange County on September 18 around 8:40 a.m. LVN 1 discovered him with a bump on his right forehead after the unwitnessed fall.
The nurse placed the resident back in bed with help from a certified nursing assistant. She contacted the physician at 9:05 a.m., who immediately recommended transferring the resident to a hospital for evaluation and treatment.
But LVN 1 didn't call 911 until around 10 a.m.
Instead, she first contacted a regular ambulance service. The company told her that since the resident was on blood thinners and had a head bump, she should call 911. She tried another regular ambulance company and received the same instruction.
Only then did she contact emergency services.
Paramedics arrived at 9:50 a.m. and transported the resident by gurney at 9:58 a.m. The resident had fallen approximately two feet from his bed to the ground, striking his head.
A CT scan at the hospital revealed a 2-millimeter right frontal subdural hematoma — a brain bleed.
The facility's own Director of Nursing confirmed that LVN 1 should have called 911 immediately. During an October 2 interview, the DON stated that residents who have unwitnessed falls while on blood thinners should be transferred to a hospital via regular ambulance or 911.
When asked what would determine calling 911, the DON said if the resident had a bump or headache.
The resident had both.
"The licensed staff should have contacted 911 for Resident 1," the DON told inspectors.
The resident had no capacity to make medical decisions according to his medical records. His health and physical examination from April showed the extent of his cognitive impairment from his brain injuries.
Federal inspectors found the delay had the potential to negatively affect the resident's well-being because necessary care and services were not provided promptly.
The case illustrates how protocol failures can compound medical emergencies. Blood thinners, also called anticoagulants, prevent clotting and increase bleeding risk. Head injuries in patients taking these medications require immediate medical evaluation because even minor trauma can cause dangerous internal bleeding.
The facility's own policies supported immediate emergency response for residents with head injuries while on blood thinners. Yet the nurse's decision to try regular ambulance services first cost precious time.
LVN 1 told inspectors during an October 1 interview that she assessed the resident and saw the forehead bump before helping him back to bed. She acknowledged that the physician ordered the hospital transfer for evaluation after being notified.
The inspection was conducted as a complaint investigation on October 9. The Director of Nursing and Medical Records Director were informed of the findings during a telephone interview on October 10 and acknowledged the deficiency.
The resident's fall occurred during the early morning shift when staffing is typically at its lowest levels. The unwitnessed nature of the fall meant staff had no immediate knowledge of how he landed or the force of impact.
Medical records showed the resident was admitted to the facility on an unspecified date with complex neurological conditions requiring careful monitoring. His diagnoses of anoxic brain damage and traumatic brain injury made him particularly vulnerable to complications from additional head trauma.
The inspection report classified the violation as causing minimal harm or potential for actual harm. However, subdural hematomas can be life-threatening, particularly in patients with existing brain injuries and those taking anticoagulant medications.
The case was cross-referenced with another deficiency, suggesting the facility had multiple care provision failures during the same inspection period.
Healthcare Center of Orange County operates at 9021 Knott Avenue in Buena Park. The facility was required to submit a plan of correction addressing how it would prevent similar delays in emergency response.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Healthcare Center of Orange County from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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