Complaint Investigation Report

Personal Rights: Staff left resident unsupervised resulting in an injury. During IBs investigation, it was discovered that on 01/01/25, R-1 experienced a fall at the facility while in the bathroom. It was revealed that R-1 is legally blind. R-1 was initially escorted to the bathroom by S-2 who then momentarily left R-1 in the bathroom while S-2 tended to another resident. S-1 was also present at the facility at that time. Staff interviews revealed that R-1 was equipped with a pendant around R-1’s neck which allows for R-1 to notify staff when R-1 needs assistance. Staff interviews revealed that at the time of the incident, R-1 pressed their pendant alerting them R-1 was done in the bathroom and needed assistance. Interviewed staff indicated they were both tending to other resident at that time and could not assist R-1 in the bathroom right away. During IBs investigation, S-1 also acknowledged that S-1 instructed S-2 to wait because, in the past when R-1 would push the pendant requesting assistance R-1 would not quite be ready. By the time S-2 proceeded to the bathroom to assist R-1, R-1 was discovered laying on the bathroom floor and had already put their diaper on. Interviewed staff indicated they observed an injury to R-1’s left eye as a result of the fall. Per hospital records obtained, as a result of R-1’s fall, R-1 sustained an “impacted femoral neck fracture of the right hip” which required surgery and had a laceration of the left eye cornea. Interviews and documentation corroborate this allegation.

Deficiency cited. Refer to LIC 9099D. Due to the seriousness of R-1’s injuries, an immediate Civil Penalty of $500.00 is being issued during today’s visit.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED .

An exit interview was conducted. A copy of this report and appeals rights were provided to Maria Isabel Tangonan.