Complaint Investigation Report

Allegation: Staff did not report an incident involving resident as necessary.

It is alleged that staff did not report an incident involving resident as necessary. Regarding this allegation it is reported that staff failed to report that Client #1 (C1) fell in a timely manner. Interview with Administrator revealed that C1 did not report any falls to Administrator. Administrator states that C1’s social worker visited C1 on 3/26/25 and that according to social worker C1 reported to social worker that C1 fell on 3/17/25 during the morning shower. Administrator states that same morning C1 had a doctor’s appointment, that Administrator took C1 to, and C1 did not report to provider either. Administrator states that C1 was not in any visible discomfort or pain. Administrator states that they sent in the SIR within the seven (7) days as required by Community Care Licensing (CCL), from the date of 3/26/25 when they were made aware of the alleged fall. LPA confirmed that SIR was sent in on 04/01/25 and 04/02/25. Administrator provided proof of fax confirmation with 4/02/25 as the date of when SIR was faxed to CCL. Interview with Staff #1 (S1) revealed that S1 was the staff on duty when C1 allegedly fell in the shower, however S1 states that they failed to report the fall to Administrator in a timely manner. S1 states that C1 fell in the shower however when C1 exited the shower C1 was not in any visible pain or distress and continued about their morning as usual. S1 admits to failing to report C1's fall due to forgetting. Interview with C1 revealed that C1 fell in the shower in the morning but that C1 did not report it to Administrator, nor did they report it to the provider that C1 saw that same day. Interview with two (2) additional staff revealed that a fall was not reported to them, however they did witness C1 limping when C1 returned later in the day from attending program. However, they did not report it to Administrator, they only wrote it on the daily log. Therefore, based on interviews, file review and observations this allegation is deemed substantiated.

Citation issued. Appeal rights discussed and provided. Exit interview conducted. Copy of report provided to Administrator.