Complaint Investigation Report

LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Daisy Fitter, and obtained the following documents for Residents# 1-4 (R1-R4): Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA did not observe any immediate health and/or safety concerns.

Regarding the allegation: Due to staff neglect, residents fell resulting in injury, it was alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Staff/Caregivers discovered R3 on the floor near the R3’s bed. Staff put R3 back in bed and staff did not notify the Facility Administrator of R3s fall. Staff did not assess R3 after the fall. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported to being aware that R3 has a history of fall and R3s family member supplied the facility with a Life Station device that would alert 911 if R3 fell in the facility, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. Resident #3 was moved to healthcare facility and was not interviewed during the investigation due to R3’s cognitive impairment. The investigation revealed that on 08/31/23, R3 fell in the facility and staff were aware of R3s fall, staff did not assess R3 for injury and did not inform the administrator of R3s fall. Additionally, staff did not seek immediate medical treatment for R3 after the 09/01/23 fall. R3 was taken for medical treatment the next day. The hospital staff assessed the R3 and observed R3 sustained multiple fractures; fracture to the left ribs, punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The facility did not properly assess R3 for injury after the R3’s fall, and it was discovered on 09/01/23 that R3 sustained serious injury.

Regarding the allegation: Staff did not seek timely medical attention for the resident, it was alleged that on 09/01/23, resident R3 had an unwitnessed fall and sustained injuries. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported that R3 has a history of fall and R3s family member supplied the facility with a Life Station device that would alert 911 is R3 fell, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Staff present during the night shift did not report obtaining medical treatment for R3 after the 08/31/23 fall.