Complaint Investigation Report

Allegation: Staff failed to provide appropriate care and supervision to resident after the fall. It is alleged that on 5/5/2022, resident (R1) sustained 2 falls. The 1 st fall occurred at approximately 7:30 PM while being provided incontinence care by caregiver (S1) in the facility common bathroom. The 2 nd fall was unwitnessed and occurred in the resident's room at approximately 8:00 PM - 8:30 PM. While staff (S1) was changing R1’s diaper in the common bathroom the resident fell to the ground. The resident was unable to get up on their own or with S1’s help due to their size. Caregiver/Staff (S1) used the Hoyer Lift to pick the resident up from the floor, and then proceeded to walk the resident back to their room. Facility staff failed to use proper equipment and follow equipment use guidelines when assisting R1 with incontinence care that resulted in the first fall in the bathroom. Staff placed R1 in the bed and returned to check on the resident at approximately 8:00 PM – 8:30 PM. Staff (S1) found the resident face down on the ground beside the bed. Staff (S1) stated that they decided to place a pillow under the head, so the resident did not get hurt, since R1 was likely to fall again. Staff (S1) stated the resident only replied “okay". Based on interviews with staff on duty, staff 9S1) and CNA/staff (S2) did not provide appropriate care and supervision after both falls. Review of evidence indicates that staff (S1) placed resident in a harmful situation by placing a pillow under the head (partially covering the face) and left the resident on the floor. Emergency personnel observed the resident's bed did not have any bed rails. Proper safety measures were not in place.

Allegation: Staff did not provide medical assistance to resident in a timely manner. It is alleged that facility caregiver (S1) and Certified Nurse Assistant (CNA)/Staff (S2) failed to provide timely medical attention by not rendering or initiating CPR when resident (R1) was not responsive. The facility failed to seek timely medical attention when R1 fell the 2 nd time and was found on the floor. Emergency Medical Services (EMS) were not called almost two (2) hours after resident (R1's) 2 nd fall, instead staff (S1) placed a pillow under the resident's head. Based on the photo, the resident was left on the floor in compromised position that appears to show R1 in prone position with left arm underneath body and right arm extended out in downward position. Caregiver staff (S1) reported both falls to CNA on duty. The 1 st fall occurred at approximately 7:30 PM. The 2 nd fall occurred at approximately 8:00 PM – 8:30 PM. At approximately, 9:30 PM, caregiver returned to the room to check on the resident because 2 other residents were heard screaming from R1's room. The resident was still laying on the ground with head on the pillow. Staff (S1) allegedly placed their index finger under the resident’s nose to see if any air was coming out from the nose. Staff (S1) stated the they felt air and left without providing further aid. According to staff interviews, staff (S1) reported the falls to Certified Nurse Assistant (CNA)/staff (S2). Sometime between 9:00 PM - 9:30 both staff went to check the resident. CNA stated that they stood by the door while staff (S1) checked on the resident and stated that staff (S1) reported the resident was okay. At 10:11 PM staff called EMS and reported to dispatcher that the resident was conscious. At 10:14 PM, EMS personnel arrived at the facility and found the resident "Dead on Arrival". Time of death was 10:17 PM. Paramedics determined the resident had been deceased longer six minutes.