Complaint Investigation Report

Resident sustained hip fracture due to staff neglect. – SUBSTANTIATED

It was reported that Resident 1 (R1) was found on the floor in the middle of the night. Staff reportedly picked R1 up and placed them back in bed.

LPA reviewed incident reports related to R1 being found on the floor after an unwitnessed fall in their room and R1 expressing pain and being transported via EMS to hospital the next morning. LPA reviewed LIC602 Physicians report which states that R1 has a diagnosis of age related dementia.

During interviews it was learned that Staff 1 (S1) found R1 on their floor on 03/15/2026 at 02:44 AM. Staff 2 was called to assess R1 and rather than call EMS to assess R1 for injury, which is the facility’s protocol, they chose to place R1 back in their bed. On the morning of 03/15/2026 at 09:20 AM during staff rounds that R1 expressed an extreme amount of pain. EMS was called immediately and R1 was transported to the local hospital where they were treated with emergency surgery for a fractured hip.

This allegation is substantiated. As a result of R1 suffering bodily injury and having to wait more than six hours in pain before EMS was called an immediate civil penalty in the amount of $500.00 is being issued this day and is documented on the attached LIC421IM.