Complaint Investigation Report

. The investigation revealed the following:

Allegation: Resident sustained a fracture due to staff neglect

It is alleged that C1 sustained a fracture due to staff neglect. This allegation was investigated by Investigations Branch (IB) investigator J. Canto which revealed the following:

During interviews with facility staff members and C1’s mother it was revealed that C1 was not at his/her baseline and appeared to be in distress and pain on or about 08/13/2024. Facility reported to C1’s primary care physician who ordered x-rays and prescribed pain medication. It was revealed C1 sustained a tibial fracture. The facility staff theorized the injury may have occurred during repositioning or the use of Hoyer lift. Primary care physician was also interviewed, theorized the incident occurred during repositioning or transfer. Based upon interviews and record review fracture occurred but there was no evidence that C1 sustained fracture due to staff neglect.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to RN.