Complaint Investigation Report

Allegation: Staff did not properly transfer resident resulting in resident sustaining a fracture

During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) & R1’s responsible party (POA) and reviewed resident (R1) documents. Staff stated that R1 requires assistance with all activities of daily living and that a Hoyer lift is required to move R1 from the bed to her wheelchair. Review of R1’s documents showed no previous falls were documented or reported. On 05/26/25, R1 had an unwitnessed fall in her bedroom at approximately 0530 hours. Staff evaluated R1 and no injuries or complaints of pain were noted at the time of her being found. R1 went about her day as normal. Around 1000 hours, R1 complained of pain to staff who sent her to the hospital. Review of R1’s medical records showed R1 was admitted to the hospital on 05/26/25 and discharged on 06/01/25. R1 was diagnosed with a “right distal femur fracture.” R1 stated that she did not remember how she got on the floor. R1 noted that her bed had bed rails and believed she must have just “rolled off the bed”. Staff stated they did not know how R1 ended up on the floor in her room at 0530 hours on 05/26/25. 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 staff did not properly transfer resident resulting in resident sustaining a fracture is unsubstantiated.

During investigation, the Department conducted interviews of residents (R1, R2, R3) and facility staff (ADM, S1, S2, S3, S4). Review of police report dated 06/15/25 showed S3 denied punching R1. During visit, police officer checked R1’s stomach and did not see any bruising or marks. Residents (R1, R2, R3) denied any abuse (physical or verbal) from staff. During unannounced visits on 05/21/25, 08/20/25 and 1022/25, LPA did not observe staff hit, punch, abuse or mistreat any resident at the facility 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 staff punched resident in care is unsubstantiated.