Complaint Investigation Report

Resident developed pressure injuries while in care.

On the allegation that ‘Resident developed pressure injuries while in care’; it is the complainants concern that a resident developed pressure injuries while in care. To investigate the allegation the LPA interviewed the resident’s responsible party (RP). The RP stated that the resident did not develop the injury while in care, and furthermore the resident was receiving care by a hospice agency. The LPA requested medical documents and conducted record review. The record review indicated that the resident was receiving care by a hospice agency.

Based on the information received through interviews and record review, there is not sufficient evidence to support the allegation that the resident developed pressure injuries while in care. Therefore, the allegation is deemed Unsubstantiated at this time.

Residents are sustaining falls while in care.

On the allegation that ‘Residents are sustaining falls while in care’; it is the complainants concern that residents are sustaining falls. To investigate the allegation the LPA interviewed residents, staff, and administrator. Three out of three residents stated that they had not sustained falls. The LPA interviewed the staff #1 (S1)who stated that some residents are at risk of falls, however S1 stated that they monitor the residents while they are awake, and sometimes the residents get up in the early hours of the morning or night and they may sustain falls while trying to get up from the bed or go to the bathroom on their own. The resident's room has a night signal to ask for help when needed. The interview with the administrator revealed that two residents have sustained a fall within the last two months; the administrator emailed the Incident Report to the licensing department and informed the residents’ responsible parties of the falls sustained by the residents.

Based on the information obtained through interviews, and record review, although there is sufficient evidence to support the allegation that two residents out of five residents sustained falls while in care, the falls occurred while the resident attempted to independently go to the bathroom either at night or early morning. Therefore, the allegation is deemed Unsubstantiated at this time.