Complaint Investigation Report

Allegation: Multiple residents fell due to staff neglect

During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Staff (S1) stated resident (R1) is checked 4 times per shift since she is identified as a fall risk. She requires 1 person total assist in bathing (2X per week), total assist in dressing, preparation of grooming items, toileting, wheelchair escort to and from activities, meals, transfers, medication assist and is a fall risk, Her care is a level 5. Review of R1's incident reports submitted to CCL dated 11/16/22 (8:15PM), 12/31/22 (12AM), 02/19/23 (6PM) and 02/28/23 (7PM) show R1 had several un-witnessed falls. R1 told staff that she was trying to get up and slid down from the bed. Med tech checked R1 and no injury was observed. R1 denied pain. Med tech and 3 care staff helped her get up and lay her down the bed. Staff notified authorized representative and primary care physician. Review of R2's incident reports submitted to CCL dated 11/28/22 (3AM), 12/03/22 (8PM), 12/24/22 (2AM) show R2 had several un-witnessed falls. While doing rounds and safety checks, med tech and care staff found R2 on the hallway floor close to his room. R2 stated he was walking using his walker and lost his balance and fell. Med tech and care staff checked R2 for injury. R2 stated he did not hit his head. Staff called 911 and R2 was sent to the hospital for evaluation and treatment. Staff also notified authorized representative and primary care physician (PCP). R2 came back to the facility with no new orders or diagnosis. A PCP follow-up video call was done on 12/29/22.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of multiple residents fell due to staff neglect and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of multiple residents fell due to staff neglect is unsubstantiated.