Complaint Investigation Report

During today’s visit, the LPA and AA conducted a physical plant tour at 10:16AM, and no immediate concerns were observed. The following was then determined:

Allegations: “Staff did not seek timely medical care for resident resulting in hospitalization on multiple occasions,” “Staff neglect resulted in resident sustaining a fracture due to multiple unwitnessed falls,” “Staff did not assist resident with personal care needs in a timely manner,” “Staff did not ensure a functioning signal system was accessible to resident,” “Staff did not ensure resident’s room was maintained in clean condition,” “Staff did not provide adequate laundry services to resident,” and “Staff did not provide resident with adequate personal care supplies”

It was reported that Resident #1 (R1) was hospitalized due to sepsis, pneumonia, and a collapsed lung and that R1 sustained multiple falls resulting in a shoulder fracture due to staff neglect. It was further reported that staff did not provide timely assistance with personal care needs in addition to providing services such as housekeeping, laundry, and personal care supplies. It was also alleged that the facility did not ensure R1’s call signal system was functioning and accessible.

Staff reported that upon admission to the facility, R1 did not require assistance; however, approximately two (2) to six (6) months prior to the allegations, R1 began needing help with showering and toileting/incontinence care. Staff stated that R1 routinely refused assistance and attempted to complete these tasks independently despite needing support. Staff reported making daily attempts to provide care, but R1 was often verbally aggressive and would not allow staff to enter their room for housekeeping, personal care, or routine checks. R1 also did not make requests for staff assistance. Staff reported that they were occasionally successful in assisting R1, but it was infrequent due to R1’s refusals. Staff did not recall the fall that resulted in a fracture and denied observing R1 with a cough or being aware of any hospitalization for sepsis, pneumonia, or a collapsed lung.

Interview with the ED supported staff’s statements regarding R1’s noncompliance. They reported that on 05/07/2024, R1 fell while showering and transported to the hospital for right shoulder and upper arm pain, where they were diagnosed with a right humerus fracture.