On July 15, 2018, Cross disappeared from her home. She had wandered out of her home on prior occasions and, in 2016, was diagnosed with dementia. She lived with two of her daughters, Lisa Cross Vasallo and Valerie King. According to Vasallo, Cross had never fallen or fractured her hip before her admission to San Gabriel and was able to walk without a cane or walker. Cross had suffered from a hernia for 40 years.
The police found Cross in the midst of traffic and brought her to Intercommunity Hospital on a Welfare and Institutions Code section 5150 hold. She remained there for 24 hours, waiting for an available bed at San Gabriel’s geriatric psychiatric ward, referred to as the behavioral unit. One of Cross’s daughters stayed with her overnight at Intercommunity Hospital, and Cross did not appear to have a fractured hip or suffer any injury or fall there.
- Cross Is Transported to San Gabriel
On the evening of July 16, 2018, emergency medical technician (EMT) Jacob Guerrero and his partner arrived at Intercommunity Hospital to transport Cross to San Gabriel via an ambulance. Because Cross was agitated, the Intercommunity Hospital nurse gave Cross an Ativan shot before the transport. The nurse also advised the EMTs of Cross’s condition and did not report that Cross was suffering from a hip fracture, which Guerrero would have noted on his transport assessment report. Guerrero observed that Cross was able to move her right leg without any problem and did not exhibit any pain. Further, no deformity, contusion, abrasion, or rigidity of Cross’s hips was found, and Guerrero concluded that Cross did not have a hip fracture. However, during cross-examination, Guerrero acknowledged he never observed Cross sit up, stand, or walk.
The EMTs placed Cross on a gurney at Intercommunity Hospital, and left there at 6:41 p.m. Upon arriving at San Gabriel, the EMTs transferred Cross from the gurney to a bed. Cross did not fall or sustain any injuries during the transfer.
- Cross’s Stay at San Gabriel
- July 16, 2018
By 7:30 p.m. on July 16, 2018, Cross was at San Gabriel. San Gabriel’s behavioral unit had approximately 22 rooms and 42 beds for people over 60 years of age who were suffering from behavioral or mental health issues. The majority of the patients in the unit were high fall risks.
Cross’s daughters followed the ambulance from Intercommunity Hospital to San Gabriel. When they arrived, Cross was already in bed, “out cold” and “[a]sleep.” They were not permitted to stay overnight.
Registered nurse David Lee was the first San Gabriel nurse assigned to care for Cross. His regular shift was 7:00 p.m. to 7:00 a.m., and he had approximately five or six patients each shift.
At approximately 7:30 p.m. on July 16, 2018, Lee conducted an initial physical assessment of Cross. She did not complain of pain and had full mobility, a bruise on her left foot, an inguinal hernia in her abdomen, and no history of falls. In the category of ambulation and balance, Lee indicated, “ndependent/[s]teady gait/[i]mmobile.”
As part of the assessment, Lee evaluated Cross’s fall risk. A score of 90 or greater indicated a high fall risk, and Cross had a score of 108. Using an electronic form, under the section for “musculoskeletal/fall risk/patient safety,” Lee checked the box “[a]t risk for falls.” However, in the section for “fall risk interventions,” he checked boxes for “[s]afe environment maintained” and “[o]rient patient to surrounding” under the heading “No Risk: 0-89.” Lee did not check any boxes under the heading “At Risk to Fall: >90,” which included “[f]all risk ID band on,” “[y]ellow gown and non-skid socks are in use,” “[f]all risk sticker on chart,” “[s]upervise/assist with ADL’s [activities of daily living],” “[b]ed alarm is on,” “[t]oileting rounds hourly,” “Q15 min observation,” and “[m]ove patient close to nurse’s station.”
According to Mariano Gallegos, the clinical coordinator for the behavioral unit, all patients who came into the unit were high fall risk and required a fall prevention plan. For a score greater than 90, the nurse should have checked some of the high fall risk interventions boxes. However, nurses also communicate a patient’s needs through notes and narratives.
When asked why he did not check any of the boxes for a fall risk score over 90, Lee testified, “maybe it was timing,” noting he had six patients to take care of or that he may have simply forgotten. As the nurse conducting Cross’s initial assessment, Lee was responsible for creating her fall prevention plan. He observed, however, that the fall risk score is updated, if needed, every shift. Further, if an oncoming nurse wanted to see what fall interventions were in place, that information could be found in “a lot of places and documentation.” “Fall precautions, which include[ ] a [15]-minute rounding observation[,] . . . are already in place . . . . So, [he] didn’t checkmark them, but they are implemented.”
- [i]July 17, 2018
At 3:52 a.m. on July 17, 2018, Lee amended Cross’s ambulation and balance characterization to read, “[u]nsteady/[r]equires [a]ssist[ and a]ware of [a]bilit[y].” Lee observed Cross was confused and could not follow simple directions. Additionally, when he changed Cross’s diaper, she did not exhibit pain, although this could have been due to medication causing her to be in a deep
