Complaint Investigation Report

R1 was taken to the hospital and was diagnosed with a brain bleed injury. Since October 2021, R1 was residing at a Skilled Nursing Facility for walking rehabilitation. R1 then returned to the facility on 12/09/21. R1 is ambulatory and did not have an assigned one on one caregiver while a resident of this facility. Interview conducted with Administrator revealed that on 12/10/21 R1 suffered an unwitnessed fall around 11:35am. A housekeeper heard a noise in the hallway and saw R1 on the floor. Housekeeper called for help and 911 was immediately called. R1 was transported to the hospital. Interviews with staff members revealed that residents are checked on at least every 2 hours. 5 out of 5 residents interviewed indicated that staff members will assist them with their activities of daily living within a reasonable amount if time. 5 out of 5 residents interviewed indicated that they feel that there is a sufficient amount of staff available at the facility to meet their needs. LPA pulled emergency cord in a random resident room during tour and observed staff responded to the call in less than 5 minutes. LPA did not obtain any evidence during investigation indicating that R1's fall was due to staff neglect or as a result of lack of supervision. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.