Complaint Investigation Report

Regarding Allegation #1: this investigation revealed that Resident #1 was transported to Providence Little Company of Mary Medical Center on 03/23/20 with a right thumb fracture, blunt head trauma, chronic anti-coagulation, and dementia. Resident #1 also had a large amount of soft tissue swelling on the left side of her head, but scans showed no evidence of an acute skull fracture or brain bleed. The two caregivers S1- S2 that were present during the fall both presented contradictory statements and were inconsistent in their interviews. Staff #1 claimed she was in the hallway when Resident #1 fell. Staff #1 stated that Staff #2 pushed and guided Resident #1 through the bedroom door towards the restroom – which was approximately 15 feet away from Resident #1’s bedroom. Both caregivers entered the bathroom with Resident #1 when she slid out of her wheelchair and hit her head on the floor. Staff #1 was in the bathroom facing away from Resident #1 and Staff #2. Staff #1 stated that she did not see the fall; but, she heard a loud bang noise and believed it was due to Resident #1 hitting her head on the hard floor after the fall from her chair. Staff #2 claimed that Resident #1 had a bowel movement in bed and needed to be transported to the bathroom to be cleaned. Resident #1 was placed on a transport wheelchair then led to the bathroom with one caregiver in front and another behind Resident #1. Staff #2 claimed Staff #2 initially stated they were right next to the bathroom door when Resident #1 fell very quickly from her transport wheelchair. Resident #1 slid forward off the transport wheelchair and bumped her head on the bathroom door jamb. Upon a follow-up interview with Staff #2 , she stated that she had observed Resident #1 hit her head on the hallway floor. After the fall, Staff #2 stated that Resident #1 sat on the hallway floor in a daze. Staff #2 noticed a bump on Resident #1’s head immediately. Staff #2 stated that she put ice on Resident #1’s head injury and called 911 immediately. Staff #2’s narrative did not coincide with the narrative given by Asst. Administrator. Staff #2 stated she called 911 immediately, while Asst. Administrator claimed that she put ice on Resident #1’s head injury and called 911 immediately. Review of Resident #1 records revealed Resident was a fall risk. Staff #2’s inconsistent interview responses and both witness’ contradictory statements placed doubt on how well Resident #1 was being supervised before the fall and how well Resident #1 was being taken care of while being transferred to the bathroom.

Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: Resident sustained injuries while in care is found to be SUBSTANTIATED.