Complaint Investigation Report

Allegation: Staff left a resident unattended. It was reported that 95 year old resident fell in the bathroom on 7/17/2024 between the hours of 10PM -11PM, and laid on the floor for hours until morning the next day. A total of 7 staff were interviewed. The staff person that was in charge of R1's care during the NOC shift on 7/17/24 no longer works at the facility; therefore, was not interviewed. According to staff interviews, resident (R1) was found on the floor the next day (7/18/2024) at approximately 7:30 AM. The resident returned to the facility the same day of the fall, after completing rehabilitation orders following a hip replacement surgery in June 2024. Based on observation, resident rooms have pull string signal system in the resident's room and bathroom, and also provide a hanging or wrist pendant to residents. Resident (R1) was wearing the signal system wrist pendant at the time of the fall. However, the wrist pendant was inoperable. The resident was not able to reach the signal pull strings in the room due to injuries. Caregiver responsibilities include checking on residents every 2 hours, or 30 minute to 1-hour checks after resident's return from the hospital because residents may be weaker or have changes in condition. A total of 11 residents were interviewed, of which 5 residents stated that NOC shift staff sometimes take 45 minutes to 1 hour to respond to signal system. On 7/23/2024, LPA tested R1's signal wrist pendant and it was not operable. The findings reveal that R1 fell and none of R1's attempts to receive assistance were answered, and staff did not check on the resident between the hours of 10 PM - 7:30 AM. Based on record review, there is no documentation that R1 was being checked more frequently after returning from the hospital, nor whether the NOC shift caregiver (S8) was aware that the resident had returned from the hospital. There is sufficient evidence to corroborate the allegation.

Allegation: Staff did not ensure a resident's alert device was properly operating. It is alleged that R1 was not able to receive staff assistance or medical attention in a timely manner after falling in the room. The resident attempted for hours to call staff for assistance by pressing the bracelet/watch pendant, but it was not working. On 7/23/2024, LPA tested the wrist pendant and confirmed it was not operating. Staff interviewed stated the signal pull strings in resident rooms and bathrooms work, but stated that some residents had been provided wrist or hanging neck pendants for use. However, staff stated that they failed to check on wrist/neck pendants regularly, and were unaware that they were not operable. Resident interviews revealed, that not all residents were given or use wrist/neck pendants, but had heard residents complain to Administration staff that the wrist/neck pendants were not operating properly. During both visits, the signal system was tested. It was observed that the Memory Care Unit signal system is separate from the Assisted Living area of the facility. This facility does not have signal system pagers that alert staff on duty when a resident requires assistance. Based on observation, there is sufficient evidence to corroborate the allegation.