Complaint Investigation Report

During today’s visit, the LPA and ACDs conducted a physical plant tour at 1:40PM and no immediate concerns were observed. The following was then determined:

Allegation: “Due to staff negligence, resident fell resulting in an injury”

It was reported that Resident #1 (R1), a known fall risk, sustained a fall on 06/18/2025 that resulted in a sprained ankle due to staff negligence. Interviews with five (5) residents revealed that falls do not often occur in the MCU and that staff are consistently nearby to provide assistance. Residents reported utilizing assistive devices such as walkers and wheelchairs to prevent falls and stated that staff respond immediately and appropriately if a fall does occur.

Staff interviews revealed that fall prevention protocols included motion censored floor and bed mats, bed rails, fall detection cameras in each resident room, and monitoring for behavioral changes. Staff reported that falls in the MCU are infrequent and, when they do occur, they are often “staff assisted,” meaning staff guide residents safely to the floor. Unwitnessed falls reportedly occur on average zero (0) to one (1) time per month. Staff stated that fall procedures include notifying all staff via radio, ensuring the resident is safe, and placing a pillow under the resident’s head. The med-tech and LVN (nurse) then assess the resident’s condition, including range of motion and pain. The LVN also reviews fall detection footage to confirm the fall and determine whether the resident may have hit their head and then decides if hospital transport is necessary and notifies the resident’s family and hospice agency.

Staff reported that R1 was initially capable of independently ambulating and required minimal staff assistance with activities of daily living (ADLs). Over time, R1’s condition declined and R1 required assistance with all ADLs. R1 was considered a fall risk when ambulating due to unsteady, shuffling, and twisting feet and required arm support for balance. Staff preferred utilizing R1’s wheelchair for transfers and escorts and reported that R1 received physical therapy (PT). Staff stated they expressed safety concerns to R1’s family; however, the family insisted that staff continue assisting R1 with walking.