Complaint Investigation Report

Obtained actual staff work schedules (months of July 2021 and August 2021), Facility Sketch, Facility Sign-In/Sign-Out sheets (month of August 2021), Daily routine schedule, and House Rules. A separate investigation was conducted by the Department of Social Service Investigator (Douglas Real) which included a review of medical records and interviews with facility staff and medical services staff.

Regarding Allegation #1 : this investigation alleges that Resident #1 sustained a fractured right hip while in care at the facility. Prior to moving into the facility on 08/17/19, Resident #1 fell at their home and sustained a broken left hip. Reporting Party told I.B. Investigator Douglas Real on 09/03/21 that they claimed to have evidence to support neglect by the facility; but Reporting Party was unable to provide evidence by the close of this investigation on 01/27/22. Hospital records obtained had indicated that Resident #1 was admitted to the hospital on 08/27/21 and had sustained a sub-capital fracture of the right hip after a fall from the resident’s wheelchair in their bedroom. Surgery was performed and Resident #1 was discharged from the hospital on 09/05/21 to a skilled-nursing facility (SNF) for rehabilitation, per a courtesy call from the resident’s Conservator. No abuse or neglect concerns were noted in the hospital records nor law enforcement or DA involvement. Resident #1 could not recall falling in the facility because of the resident’s cognitive diagnosis. Resident #1 was listed as not being able to independently transfer to/from bed (non-ambulatory). Facility employees reported monitoring Resident #1 more frequently due to their fall-risk behavior. Residents interviewed corroborated that facility staff are helpful and respond quickly when asked to help and provide an appropriate level of care and supervision. Residents interviewed have not observed facility staff harm or neglect residents in care. Resident #1’s Conservator and responsible person were very pleased with the level of care and supervision that Resident #1 was receiving at the facility.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained a fractured hip while in care is found to be UNSUBSTANTIATED.