Complaint Investigation Report

Allegation: Resident sustained a fracture while in care.

LIC602A Physician’s Report showed R1 as non-ambulatory, cannot bathe self and not able to care for own toileting needs. FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers. FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. Incident reports dated 2/27/23, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 noted R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Incident report dated 7/26/23 noted that R1 was helped up from bed and was about to walk with walker to the bathroom when R1’s legs gave out and R1 indicated her legs getting weak and were hurting. R1 fell on her knees and facility staff helped R1 sit up. Lift assist was called to help get R1 up, but R1 could not get up after several attempts with the medics. R1 was taken to the hospital. Medical Records reflected that R1 sustained a displaced supracondylar fracture without intercondylar extension of the lower end of her left femur. Based on records review and interviews, the allegation is substantiated.

Allegation: Resident had multiple falls during transfers.

FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers.FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. Incident reports dated 02/27/2023, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 note R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Lift assist had to be called each time in order to get R1 up. Facility staff admitted that R1 would fall “every single day”. All facility staff interviewed stated they did not believe they could provide the level of care R1 required but kept R1 at the facility anyway. In April of 2023, R1 returned from the hospital to the facility confined to a wheelchair, however, the wheelchair did not fit through R1’s bedroom or bathroom door. Two facility staff would have to physically lift R1 out of R1’s wheelchair and into a standing position supported by R1’s walker. Facility staff would then walk behind R1 as she walked into her bedroom and bathroom. R1’s physical condition prevented her from walking at all which caused R1 to fall constantly. Therefore, the allegation is substantiated.