Complaint Investigation Report

The investigation revealed the following: Regarding the allegation, “Staff do not properly address client’s multiple falls,” it is being alleged that staff did not take appropriate action to address C7’s falls and reduce the risk of additional falls.

Interviews conducted revealed the following: S1 stated that staff increased supervision, reminded C7 to use a cane, and contacted DHS for an assessment. S1 reported that the incident on 05/20/2026 was not an actual fall; C7 experienced weakness, felt that might fall, requested medical attention, and was transported to the hospital. S2 reported that staff increased supervision, provided full-care assistance, and reminded C7 to use the cane, although C7 did not consistently use it. S3 reported that staff monitored C7, assisted while walking, and walked to and from room and the restroom. C1–C4 did not report observing relevant falls or concerns regarding staff assistance. C7 confirmed falling but was unable to recall the details. W1 reported recommending increased supervision, specialty medical referrals, a helmet, and bedside rails. W1 reported returning to the facility on 06/01/2026 to follow up and stated that staff appeared to be assisting C7. W1 did not report concerns regarding the facility’s response. Records review revealed the following: Hospital records documented that C7 was transported to the hospital on 05/20/2026 after a reported fall while walking to the restroom and returned to the facility on 05/21/2026. A staff communication dated 05/19/2026 instructed staff to increase supervision for C7. Two-hour supervision check logs for C7 dated 05/19/2026 through 06/03/2026 documented continued monitoring. W1 recommendations included increased supervision, specialty medical referrals, a helmet, and bedside rails. A fax confirmation dated 06/03/2026 documented continued home-health follow-up regarding referrals. Observations revealed the following: During the interview, C7 had difficulty explaining responses, repeated words, and was unable to recall details regarding the fall. Based on the evidence gathered, interviews conducted, observations, and records reviewed, although the allegation, “Staff do not properly address client’s multiple falls,” 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 is UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided to the administrator.