Complaint Investigation Report

of resident, staff, other residents and Administrators on January 18, 2020; January 21, 2020; January 24, 2020; January 30, 2020; and February 04, 2020.

Based on interviews, R1 was admitted to the facility on August 08, 2018, with several physical and mental disabilities and labeled as a “high fall risk”. Based on a physician’s report dated September 10, 2019, R1 was non-ambulatory and should not ambulate, transfer, or toilet without assistance; and needed assistance with activities of daily living (ADL’s). Incident reports and facility documents revealed that R1 had prior unwitnessed falls. As a result of the falls, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). On January 15, 2019 and December 28, 2019, R1 continued to have falls, as well as behavioral issues in the night in which R1 sustained injuries and staff had difficulty keeping R1 in the bed.

On January 15, 2019, it was documented that R1 was agitated and attempted to get out of bed and was assisted by staff. Somehow an unwitnessed fall occurred and R1 got out of bed alone, fell backward, and hit R1’s head on the wall. R1 sustained “several bumps.” On December 28, 2019, at 4:50am, R1 attempted to get out of bed and climbed over the bed rails. It was reported during the investigation by IB Investigator Santana that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. The improper use of bed rails caused the impact of the fall to be more severe. Further, staff left R1 unattended even though R1 was at risk of attempting to get out of bed. R1’s history of attempting to get out of bed is evidenced by R1 being on anxiety medication to control R1’s behaviors, and staff installing a motion sensor in order to prevent resident from getting out of bed. The facility accepted and retained the resident, knowing R1 was a “high fall risk.” Due to the lack of care and supervision by staff, R1 sustained multiple bruises and a head injury. Also, during the incidents of the falls, facility staff failed to seek medical attention and notify R1’s responsible party in a timely manner. This is an immediate health and safety risk to residents in care. Therefore, there is evidence to corroborate the investigation conducted by IB, and the allegation “Use of Improper Restraints Resulting in Injury to Resident”, is Substantiated.