Complaint Investigation Report

Allegation: Resident sustained a fall while in care

R1 passed away on 1/26/22 and review of the hospital records indicate that during the external examination, there was no evidence of injuries pertaining to a fall with no fractures or disassociations, and no epidural or subdural hemorrhage. Manner of death was deemed natural and unrelated to the fall of 1/24/22. Review of R1s file indicate that R1 was not a fall risk. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

Allegation: Resident was denied access to emergency personnel

Based on interviews and record reviews, resident (R1) had an unwitnessed fall at the facility on 01/24/22, with no information emerging that there had been an injury. Staff stated they offered to take R1 to the emergency room but she refused to go. On 1/26/22, R1 awoke at approximately 8:00 am. When staff went to R1s room to notify her that breakfast was ready, R1 informed staff of feeling dizzy and nauseous, and declined to eat. Staff contacted Administrator who conducted a video tele-visit with R1. At approximately 10:00 am, staff again called Administrator, who while speaking with R1, observed R1 lose consciousness. Paramedics were contacted at 10:23 and arrived at facility at 10:27 am. R1 expired while in transport to hospital. The Death Certificate lists the cause as natural, and unrelated to the fall that took place on 1/24/22. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.