Complaint Investigation Report

C1 was unable or unwilling to stand after his fall. Staff were able to put C1 on a mat and move the mat inside the facility. Interview with staff revealed that C1 was repositioned every two hours during waking hours. However, C1 would independently move back to original position. When staff asked C1 to get up, C1 refused to get up from the living room floor and go to the room. C1’s health providers were notified of the pressure injury and recommend that C1 should be off the floor. On 5/13/2020, C1 was taken to the ER.

Staff were in routine communication with C1’s health providers who advised the matter was not an emergency, and that it could wait. Record of correspondence with health providers supports staff was in regular contact with C1’s health providers regarding C1’s status. C1 fell on 5/8/2020 and staff immediately communicated the fall to C1’s health providers who advised staff to ice, elevate, and wrap C1’s ankle. Staff communicated with C1’s health providers on 5/9/2020 by sending updated photographs. On 5/11/2020, C1’s health providers responded the bruising was a sign of bleeding from torn ligaments and staff could wait another day so that an x-ray order could be written. Staff informed C1’s health providers that it would be difficult transport C1 and inquired if an x-ray could be done at the facility. Health provides advised an order would be sent to radiology and it wouldn’t hurt the situation to wait a little longer. Staff continued to update health providers with recent photographs of the injury later that evening on 5/11/2020. Health providers indicated it was not an emergency and it was superficial bleeding under the skin from torn soft tissue. On 5/13/2020, health providers recommended staff call 911.

Staff did not report C1’s initial fall that occurred on 5/8/2020. However, staff reported C1’s medical transport on 5/13/2020. Staff provided a copy of the email sent on 5/14/2020 and both incident reports. By providing the incident report to LPA on 5/15/2020, it met the requirement of submitting a written report to the Department.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED .

Exit interview conducted. A copy of this report provided.