Complaint Investigation Report

Service Plan, Healthcare Provider Communication, pendant Device Activity Report, and Staff Training Logs.

The investigation revealed the following:

Allegation: Staff did not respond to residents calls for assistance in a timely manner resulting in resident falls

The allegation alleges that a Resident pressed their call button for assistance and when staff did not come the resident got up and had a fall.

LPA received and reviewed pendant Device Activity Report and observed on 02/08/2025 at 11:07:21PM R1 pressed their pendant, it was cleared at 11:31:54AM, taking staff a total of 24 minutes and 33 seconds to respond. Additionally, LPA observed R1 pressed their pendant at 2:37:13AM, that was cleared at 3:00:25AM, taking staff a total of 23 minutes and 12 seconds to respond to the call. R1’s arrival to the Emergency Room was on 02/09/2025, at 3:46AM. Additionally, LPA reviewed a Special Incident Report (SIR) for Resident R11, that states R11 had a fall on 02/14/2025. LPA reviewed the Device Activity Report and observed on 02/14/2025 at 8:57:29AM R11 pressed their pendant, it was cleared at 9:27:52AM, taking staff a total of 30 minutes and 23 seconds to respond. LPA received and reviewed staff Charting Notes for R11 that states on 02/14/2025 Resident had an unwitnessed fall approximately around 9:15AM and Resident was found on the floor.

During interviews with Staff S1-S10, were asked if any residents experienced a fall