Complaint Investigation Report

An internal incident report is completed, and the responsible party is contacted.” S2 stated, “In this situation, we assessed and called hospice, and notification to the person in charge happened right away.” S3 provided the incident report and change of condition log, which reflected that staff documented the fall, assessment, and communication with hospice. S4 also confirmed that she notified the med tech immediately after discovering the situation.

LPA’s review of the communication logs and call logs confirmed that notifications were made to hospice and to responsible parties after the incident. Documentation reviewed included the internal incident report with instructions and protocols for care following the fall. Interviews with staff were consistent in describing the procedure: caregivers alert the med tech and unit lead, complete incident documentation, and notify hospice and the responsible party.

Allegation: Staff does not meet training requirements - Unsubstantiated

LPA reviewed three staff files (S1–S3), including annual training logs, and continuing educa tion records. LPA also reviewed R1's file. R1 is on hospice. W1 reported, “An untrained med tech who is not a nurse assessed whether or not my mother was okay.” Interviews with staff confirmed that the caregiver on duty notified the med tech, who then notified the nurse and hospice. S4 stated, “I notified the med tech right away to escalate it after finding out the situation in Room 119.”