Complaint Investigation Report

Staff did not seek medical attention for resident in a timely manner.

During the Department’s interview on 11/13/2025, W1 stated that on 8/4/2025, W1 went to the facility to drop off supplies. S2 reported to W1 that there was something wrong with R1’s foot. W1 examined R1’s foot and noticed something was wrong with R1’s left leg. R1 was transported to the hospital the same day. On 9/10/2025, the Department obtained a copy of R1’s medical record from 8/4/2025 that indicated R1 received x-rays to R1’s left foot, ankle, knee and hip. Radiology imaging showed a left distal femur fracture. R1’s orthopedic progress notes dated 8/5/2025 indicated “interval healing/callus formation suggesting at least 6+ weeks of healing”. The Department interviewed S1 on 11/26/2025, and S1 denied R1 having any falls while at the facility. S1 stated R1’s legs and knees always looked distorted, because R1 had arthritis. S1 added R1’s legs were never straight and S1 did not see anything abnormal with R1’s legs. According to S1, staff did not report to S1 of any falls. However, S1 believed that the injury occurred when “R1 would get R1’s leg on the side of the bed rail and got twisted the wrong way”.

Staff did not notify resident's responsible party of incident.

Interview with W1 revealed facility did not notify W1 of R1’s leg injury timely, W1 was informed by physician of R1's leg being injured for approximately 6-8 weeks upon admission to the hospital. Interview with S1 revealed, R1's leg was never straight and S1 believed R1’s diagnoses or caused the leg to get worst. Interview with S1 also revealed that S1 did not see a need to notify the R1’s responsible party of R1’s leg being worst. Record review revealed facility did not update R1’s appraisal needs and service plan with the change of condition and provide a copy to R1's responsible party.