Complaint Investigation Report

It is alleged that R1 sustained unexplained fractures while in care. Investigation revealed that on 03/28/22 R1 pushed against a positioning tray that R1 uses causing it to fall of the wheelchair and onto R1’s legs and feet which caused the fractures. The positioning tray broke during the time it fell. Positioning tray is specific for R1’s wheelchair and R1 has used the tray from the start of admission to the facility on 01/27/2015. Staff did not observe any discomfort in R1 on 03/29/22 and verbally informed staff to keep close attention for any change of behavior in R1. On 03/29/22 during the night R1’s right foot was observed to be swollen by staff and R1’s big toe had discoloration. R1’s physician informed staff to send pictures of R1’s injuries. On 04/03/22 R1’s podiatrist conducted a home consultation and advised staff to continue with R1’s primary physician’s plan to have an ultrasound conducted on R1’s legs. On 04/06/22 staff took R1 to see R1’s primary physician and was informed to go to the hospital for further evaluation. Emergency room diagnosed R1 with right and left ankle fractures. This incident was reported to CDSS on 03/29/22. According to the medical personnel, there is no concern for neglect/lack for R1’s safety or well-being in the facility.

Therefore, due to a lack of supporting evidence the allegation, “Resident sustained unexplained fractures while in care”, is deemed Unsubstantiated.

No deficiencies cited. Exit interview conducted. Report signed and delivered. Appeals right delivered.