Complaint Investigation Report

The investigation revealed the following:

Allegation 1: Staff failed to prevent a resident from sustaining a fracture while in care.

It was alleged that on October 24, 2024, R1 exited the facility, began walking backward, and subsequently fell, sustaining a hip fracture. R1 was transported to the emergency room and diagnosed with the injury.

LPA interviewed Staff #1–5. 1 out of 5 staff members stated they were not present during the incident and could not provide details. 4 out of 5 staff members confirmed they were present and described that R1 was attempting to leave the memory care unit. R1 exited through a secured door and began walking backward, which led to the fall. Staff arranged transport to the hospital for medical evaluation.

LPA interviewed Residents #2-8 (R2–R8), and 7 out of 7 residents denied the allegation. LPA conducted a tour of the physical plant, but no surveillance cameras were observed. A review of R1’s file, including the Physician’s Report, Needs and Services Plan, and Preplacement Appraisal, did not indicate a documented history of falls. An incident report was submitted to Community Care Licensing (CCL) for the incident that occurred.

Based on the investigation, there is not enough evidence to support that staff failed to supervise R1, resulting in the resident sustaining a fracture.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 deemed unsubstantiated.