Complaint Investigation Report

Based on the IB investigation and LPA investigation, the investigations revealed the following;

For Allegation 1 – Resident sustained multiple injuries (including rib fractures) while in care. C#1 has a history of falling, and the facility reported it to C#1’s Psychologist, two years before the time of the 3/19/2021 incident, when C#1 reportedly fell and struck the fireplace while getting up from a dining room chair. Despite Doctor’s recommendation that C#1 be seated against a wall and within a staff member’s reach while C1 has meals, in an effort to prevent sudden movements and potential falls, the facility did neither of these things at the time of the incident, resulting in his fall and head injury. The facility caregiver was unable to give a valid reason for why Doctor’s instructions were not followed, other than to say she is new to the facility and was uninformed, but the administrator acknowledged the incident could have been prevented if the strategies were followed. C#1 additionally sustained several other injuries from prior reported falls, but facility records indicate those may have been the result of seizure activity, which was actively being addressed by C#1’s doctors. The ribs fractures might have been prevented, but it cannot be assumed because of C#1 fall and head injury, the rib fracture was a result of the fall also. The facility will implement doctor’s instructions and inform new and seasoned employees of C1’s needs. The interviews and records did not concur with the above allegation.

Allegation 2 – Resident was hit by another resident resulting in hospitalization. The only indication C#1 was assaulted under the facility’s care was when another resident, C#2, bit C#1 arm. The staff member present at the time of the incident did not witness how the incident began, but staff member stated that staff member separated the residents as soon as staff member became aware of what was occurring. Because I uncovered no evidence to prove the facility’s lack of supervision resulted in the bite, the allegation is therefore Unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated

An exit interview was conducted with Sharon Hopper, Administrator, and a hard copy was provided.