Complaint Investigation Report

side. Staff #1 then pulled the resident towards them and placed part of the diaper beneath the resident. Resident #1 then had to roll over to their left side to allow staff to pull the diaper through to the other side. This was normal practice when Resident #1 was changed. On 2/16/25, Resident #1 rolled over to the left and misjudged the size of the bed and ended up on the edge of the hospital bed. Resident #1 continued to slip off the bed before Staff #1 could prevent the fall. Resident #1 landed on their left side. As a result of the fall, Resident #1 had left side pain, arm pain, bruising and swelling and lay on the floor for about 30 minutes before staff were able to transfer the resident back to bed. The acute displaced fracture of the distal humeral shaft injury was not known until 2 days later. Per the investigation conducted by Investigator Padilla, there was insufficient evidence to support the allegation that due to neglect, lack of supervision, staff caused an injury to a resident. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time.

Exit interview was conducted and a copy of this report was provided