Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not notify authorized representative of resident’s fall

The complaint allegation alleges that the resident’s responsible person was not notified of the residents fall when it occurred and was notified in an email the following day.

During review of resident R1’s Progress Notes dated on 06/16/24, LPA observed R1 was found on the floor by a caregiver, 911 was called, and the POA was called. It was indicated in the Progress Notes the POA told facility staff to cancel 911. Additionally, below the note it was indicated R1’s Responsible Person was notified as well as the Primary Care Physician. The Notes indicate on 06/19/24, R1’s Responsible Person refused to sign the Refusal of 911 Service, Transport and/or Evaluation form. Additionally, during file review LPA observed on the Resident Roster, Resident Progress Notes, Admission Agreement, and Identification and Emergency Information indicates who R1’s Responsible Person is.

During an interview with R1’s responsible party, stated they were not informed of R1’s fall till they came to the facility on 06/17/24. During the interview the responsible party stated they knew about the fall before the facility informed them because the facility staff called their sibling. Additionally, the responsible party stated they refused to sign the Refusal Form because they were never informed of 911 being called or canceled and they confirmed with their sibling that the facility staff did not mention anything about calling 911.