Complaint Investigation Report

Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls.

It is alleged that resident has fallen twice at the facility and that staff did not properly supervise resident even though they knew resident was a fall risk.

Staff deny the allegation. Interviews with (9) out of (9) staff revealed that staff are conducting safety checks and are providing proper care and supervision for residents to help prevent falls. Staff indicated that residents who are at risk of experiencing falls are provided with extra monitoring. Staff further indicated that the facility follows protocol which consists of residents being evaluated for injuries and if needed, are sent to the hospital, when experiencing a fall. Interviews with (6) out of (9) staff indicated that R1 experienced a fall on 12/27/2025 and on 1/16/2026 in R1’s room. During both incidents, R1 was checked for injuries immediately after staff responded to R1’s calls for help. R1 stated that they were not hurt and staff observed that R1 was able to move their extremities. Staff indicated that during both incidents, R1refused medical care after it was offered by staff and staff continued to monitor R1 for any changes in condition. Staff further indicated that R1 will attempt to get out of bed without requesting assistance; however, staff continue to educate R1 on the importance of calling for help when R1 needs help getting out of bed by using their call button before trying on their own. Staff stated that R1 can make their needs known. However, staff indicated that R1 gets agitated and wants to transfer from their bed to their wheelchair independently, even though R1 needs minimal assistance during transfers. Interview with R1 indicated that staff check on R1 during their rounds every two hours or more and that staff help R1 get in and out of bed when needed. Interviews with (9) out of (10) residents indicated that staff are conducting safety checks and provide them with support to prevent falls. Residents also indicated that staff are proactive if they need medical attention by calling their doctor or emergency services. Review of R1’s Care Plan indicates that R1 transfers independently, but Caregivers and Med-Techs can assist when needed. R1’s Physician’s Report notes that R1 can transfer to and from bed and does not have any motor impairments.

Staff and resident interviews, and review of R1’s records, could not corroborate the allegation that staff did not provide adequate supervision resulting in a resident sustaining multiple falls.

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