Complaint Investigation Report

Allegation: Staff did not ensure supervision was provided to resident resulting in multiple fractures from a fall.

The details of the complaint alleged that facility staff did not ensure supervision was provided to (R#1) resulting in multiple fractures from fall.

On October 20, 2025, during the records review, the Department observed documentation consistent with the facility’s reporting of the incident and subsequent monitoring of (R#1). On the same date, (R#1) sustained an unwitnessed fall. The facility caregiver conducted rounds at approximately 06:00 a.m. and observed (R#1) in bed, asleep. At approximately 06:40 a.m., during the second rounds, (R#1) was discovered on the bathroom floor of their bedroom and was assessed by the facility nurse with no visible injuries noted. (R#1) was placed on observation. On October 21, 2025, (R#1) appeared to have some pain, and the facility requested X-rays, which were pending from the medical doctor. On October 22, 2025, (R#1) had a visible change in condition and was unable to bear weight, collapsing into the arms of a caregiver. (R#1) was transported to the local hospital and admitted to the emergency room, where they were diagnosed with a large left pneumothorax, moderate left pleural effusion, and mildly displaced left posterolateral fourth through seventh rib fractures. Based on the information reviewed and interviews conducted, there was no evidence that the facility neglected (R#1)’s care.

On October 20, 2025, during interviews with witnesses (W#1–W#4), (4) out of (4) stated they had no concerns regarding the care provided to residents in care, including (R#1). Witnesses reported that during their visits, (R#1) appeared well and that they had never observed any indication of neglect by the facility. Witnesses further stated that (R#1) was consistently clean, groomed, and in good spirits. One witness reported making unannounced visits and stated they had never observed neglect of care toward any residents. Another witness stated they had never seen any signs of abuse or neglect by the facility. A witness also stated they had no concerns regarding the care provided, had never had any inclination of neglect, and was satisfied with the type of care the facility provided.