Complaint Investigation Report

Regarding the allegation "Resident sustained injury from a fall due to lack of supervision" it was alleged the facility did not prevent Resident #1 (R1) from falling due to insufficient supervision. Record review of resident supervision logs revealed staff had checked on R1 every two (02) hours prior to their fall. R1’s care plan indicated that “staff will have fall precautions in place” and “staff are to document resident’s 2 hour checks”. Interview with S3 revealed they were the first to see R1 on the floor. R1 had fallen out of bed around 4:30 a.m. on 12/01/24. S3 noted R1 was alert and oriented. S3 called Staff #4 (S4) to assess R1 for injury. Interview with S4 at 4:00 p.m. on 12/13/24 revealed R1 did not have pain and did not want medical assistance. S4 reported the fall to R1’s representative and physician. Interviews with the administrator and staff revealed that R1 has had half bed rails in place as a fall precaution. Based on interviews and record review, facility staff provided sufficient supervision to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Resident did not receive timely medical attention” it was alleged the facility did not provide or seek proper care for R1 after their fall. Interview with S4 revealed R1 refused medical attention after their fall. Interview with S3 revealed they notified R1’s home health agency of their fall on 12/01/24. Interview with S1 revealed they scheduled home health to assist R1 on 12/01/24. Record review indicated that R1’s home health agency visited on 11/30/24, 12/03/24, and 12/10/24. R1 showed no signs of distress during the visits. X-rays were performed on 12/03/24 and revealed R1 sustained no fractures or broken bones. S1 also noted that R1 reported not having any pain after the fall. R1 had no bruising until “several hours after” their fall. Based on interviews and record review, the facility offered immediate medical attention in a timely manner which R1 refused. Facility staff ordered follow-up medical attention in a timely manner as well. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report provided.