Complaint Investigation Report

• Discharge Instructions from Emanate Health Queen of the Valley Hospital dated 1/3/22 • Facility Menu

The investigation revealed the following;

Based on interviews conducted and records reviewed, LPA discovered that R1 sustained unwitnessed and unforeseen falls. The fall incidents occurred during period 1/2/22 – 1/4/22. R1 had an unwitnessed fall on 1/2/22 in the dining room. The paramedics were called and arrived but R1 refused to go to the hospital. On 1/3/22, R1’s sister was contacted by staff to help convince R1 to go to the hospital for further evaluation, at which time R1 agreed. An ambulance was called and R1 was transported to Emanate Health Queen of the Valley Hospital (EHQVH). R1 was evaluated at EHQVH and diagnosed with a supracondylar fracture of the humerus (left elbow). R1 was released shortly after in stable condition and asked to follow up with primary care physician (PCP) in 1 -2 days. R1 sustained a second fall in her room on 1/3/22, at around 8:30pm. No visible injuries were noted by staff. R1 refused to go to the hospital. R1 sustained a third fall in her room on 1/4/22 , at 6:30am. No visible injuries were noted by staff and R1 refused to be sent to the hospital. R1 expired on 1/4/22, at 8:40am. According to the Death Certificate, the cause of death was noted as Cardiopulmonary Arrest and Chronic Obstructive Pulmonary Disease (COPD). Per the Administrator, the family of R1 and R1’s PCP were notified after each fall. After reviewing the file of R1, it was noted that R1 was ambulatory and did not require assistance with her activities of daily living. Based on interviews conducted and records reviewed, R1 was not a fall risk resident and did not have a history of prior falls.

The facility provided proper treatment to R1 after her falls; observation and medical attention by staff. Law Enforcement was on scene at the time of R1’s passing but no further action was taken. Based on the investigation conducted, no evidence of Neglect/Lack of Supervision was found.

Allegation: Facility is forcing resident to use their physicians and dentist.

Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the allegation. Staff and residents interviewed stated that residents are not forced by staff to use the in-house facility physicians and dentist. Staff offer residents to use the in-house physicians and dentist in order to make it easier and convenient for the residents, but residents are never forced. Residents have the option of using an outside physician and dentist if they wish. According to the Administrator, there are many residents at the facility who use outside physicians and dentists. Based on interviews conducted, there is insufficient