Complaint Investigation Report

Allegation: Residents sustained injuries due to lack of supervision

During investigation, the department interviewed staff and reviewed resident’s (R1) documents. R1 was first admitted at the facility on 05/02/23 with chronic left facial weakness due to a stroke in 1997 as well as chronic leg swelling. She has dysphagia, dementia and is totally assisted by staff with bathing, dressing, grooming, dental care, toileting, transfers, meals and dementia care. Review of R1’s progress care notes from 06/12/23 to 02/23/24 showed staff monitored R1’s changes in condition and sent her to the hospital for treatment and evaluation on 08/13/23, 08/27/23, 12/25/23 and 02/04/24. On 01/22/24, R1 was placed under hospice care. Staff stated that they followed R1’s hospice care plan and communicated frequently with R1’ hospice care team and responsible party about R1’s condition. 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 that residents sustained injuries due to lack of supervision is unsubstantiated.

Allegation: Resident fell out of wheelchair due to lack of supervision

During investigation, the department interviewed staff and reviewed resident’s (R1) documents. LPA interviewed (S1) who stated that on 01/21/24 at around 1:37AM, R1 had an unwitnessed fall. R1 was found on the floor by caregivers during their 4X per shift status checks. R1 complained of head hurting with a large lump on her right temple. Staff contacted hospice nurse and ice was placed on the bump every 5 minutes until the swelling subsided. 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 that resident fell out of the wheelchair due to lack of supervision is unsubstantiated.