Complaint Investigation Report

In regards to the allegation "Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls" it is alleged that R1 has had multiple falls in the facility in the last year due to lack of supervision. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff only showed knowledge of one fall where R1 slipped from their wheelchair. Staff were present and able to assess R1. 911 was also called but no injuries were noted. File review shows an SIR dated 6/2/24 on the incident provided to licensing. There were no other recordings of falls R1 may have had in the facility. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff neglect resulted in resident sustaining an unexplained injury" it is alleged that due to staff neglect of supervision R1 received a unknown burn on their hand. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that blisters were observed on R1's hand on 10/8/24. Staff interviewed denied any knowledge of what caused the blisters. Interviews added that the blisters were initially observed by R1's relative while they were in private. Once staff became aware, they assessed R1 and called paramedics. There was no knowledge of the blister prior to the family visit. File review shows there is an incident report on file for this day. Staff stated there are no chemicals in the open near R1's bed and R1 receives total assistance with mobility around the facility. This means staff are present and near R1 when moving anywhere in the facility. Interview with R1's home health agency stated the blisters classify as a burn but the cause remains unknown. The blister was in between the finger and more resembled friction burn rather than a chemical burn. LPA observed R1's room to be free of any items that pose a danger. LPA observed staff supervision to be sufficient. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.