Complaint Investigation Report

The investigation revealed the following: in regards to the allegation, "Facility not providing adequate supervision resulting in resident suffering multiple falls." , it is alleged that a resident sustained multiple falls while in care of the facility. The resident has been suffering from Alzheimer/Dementia for the last "15 years." All staff members interviewed denied the allegation and stated that there's enough staff to check and attend to the needs of the residents on a daily basis. S1 stated that she ensures that the facility is fully staffed to provide proper care and supervision to facility residents. Staff members interviewed also stated that when a resident needs assistance, they use either the house phone or the pull out cord in the residents room to call. The call goes directly to the front desk and staff would use the radio to alert staff on the floor to assist the residents. At 1:30pm, LPA tested the pull out cord in a random room and staff came in 4 mins 37 secs. LPA observed enough staff caring for residents in Memory Care and Assisted Living during the visit. Based on documents reviewed, R1 has multiple falls for a period of 5 days in the facility, however, this is not due to lack of adequate supervision. The staff conduct a routine safety checks often and facility has cameras in the Memory Care unit and common areas that are operational. There are (3) Caregivers and (1) Med-Tech on schedule per shift (AM, PM and NOC shifts) who provide care and supervision to the residents. S1-S2 stated that R1 fell at the previous facility the night before being transferred to their facility. On 3/22/2023, R1's transfer date, S1 re-evaluated R1 immediately upon arrival because she observed a bruise on her nose/nostrils area and S1 had her transferred to the Hospital for evaluation. S1 stated that R1 does not have a one-on-one caregiver. S1 will meet with R1's family on 4/03/2023 to discuss her higher level of care and to possibly move her to a different facility that can meet her needs for higher supervision. S1 stated that all staff are aware that R1 needs higher supervision and extra monitoring. (9) out of (9) residents interviewed denied the allegation. All interviewed residents indicated that they feel there is sufficient staff to provide adequate supervision and monitoring to meet their needs. Residents interviewed indicated they feel safe and comfortable at this facility. Therefore there was insufficient evidence to corroborate with the allegation.