Complaint Investigation Report

Regarding allegation: F acility staff did not properly supervise residents resulting in multiple falls.

During this investigation, LPA obtained relevant documentation and interviewed staff and residents. (6) out of (8) staff interviews revealed there is sufficient staff supervision. S1 stated that the staff ratio is (1) caregiver per 5-7 residents per shift. S1 indicated that facility provides balance exercises daily for free. And facility has (3) physical therapists available for residents to help with improving their health and balance. Staff interviews revealed that staff conduct rounds every (2) two hours and as needed throughout the entire day. Interviewed staff indicated rounds are documented on a chart with the resident’s names, dates, times and staff conducting the rounds. (6) out of (8) staff indicated that they have not seen any falls or slips during their shift. (7) out of (8) staff indicated that they have not received any complaints nor concerns in regards to residents falling from any resident representatives/family members, staff nor residents. LPA reviewed R1-2 documents which indicated that they both use a walker but none of them have a history or high risk of falls. Interviewed residents indicated staff conduct rounds often throughout the entire day. (2) residents interviewed stated that they had slipped because of their health condition and not because of the staff. And they did not suffer any injuries due to the fall or slip. (9) out of (11) interviewed residents indicated that they have not fallen nor they have witnessed anyone falling. Documentation reviewed and interviews conducted with staff and residents do not corroborate this 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.