Complaint Investigation Report

Allegation #1: Staff did not assist resident in a timely manner.

In regards to the allegation it was reported Resident #1 (R1) had an unwitnessed fall in one of the facility bathrooms and was lying on the bathroom floor without receiving assistance for 30 minutes. To investigate the allegation LPA conducted interviews with three (3) out of six (6) residents and staff #2 (S2), who was present during the incident in question. LPA interview with R1, R1 affirms they had an unwitnessed fall in the bathroom while they were attempting to get out of the bathtub after the fall they eventually were able to get up and inform S2 they had a fall. Interview with S2 corroborates R1 notified them they had a fall in the bathroom. Interview with S2 revealed they did not hear R1 have a fall and didn't realize R1 was taking a shower. Interview with various resident's revealed they have waited over a minute to an hour for assistance after pushing their call button, ringing a bell or calling out for assistance. Staff schedule revealed there is usually one staff present in the AM shift and one staff present in the PM shift for six (6) residents. Staff interview revealed if staff is assisting a resident in the shower they have to complete the shower first to then be able to attend to other residents which can take over 5 to 10 minutes. Based on interviews and record review this allegation is Substantiated at this time.

Allegation #2: Staff did not provide a safe and comfortable environment for resident.

In regards to the allegation it was reported that R1's mattress needs to be replaced and the bathroom R1 one uses needs a grab bar when getting out of the bathtub. To investigate the allegation LPA conducted interviews with R1, staff and conducted a physical plant tour. LPA interview with R1 revealed they believe the fall in bathroom could have been prevented had there been a grab bar on the outside of the bathtub/shower. LPA observed the bathroom in question and although the bathroom is equipped with one grab bar by the toilet and another inside the bathtub/shower, it does not have one at reach for residents entering or exiting the bathtub. Interview with staff revealed most residents shower in the second bathroom that has a walk in shower. LPA observed the second bathroom is located farthest from the residents' bedrooms. LPA's review of R1 records revealed R1 is ambulatory, however is assisted with a device to get around. In regards to R1's mattress, LPA's review of facility records revealed facility had purchase a new mattress in May 2023 - June 2023. Administrator designee stated they have rotated the mattress but may either purchase a bed topper or take R1 to pick out their own mattress. Based on interviews, record review and LPA's observation the allegation "facility needs a grab bar" is Substantiated at this time.

Deficiencies cited on LIC9099-D. Exit interview conducted. Appeals Rights provided. Copy of report provided