Complaint Investigation Report

Resident sustained multiple falls while in care

On the allegation, ‘Resident sustained multiple falls while in care’. It is alleged that R1 has had five (5) falls since being admitted to the facility due to staff not responding to the pendant calls. To investigate this allegation, the LPA conducted interviews, and record review. On 10/26/2021, at 2:30 p.m., the LPA conducted record review and found that R1 had sustained four falls between the months of September, and October 2021. The in-house Incident Reports indicate that R1 ‘slipped’ from the bed four out of four times. The falls were described as R1 ‘slipping’ off the bed. The reports further indicate that R1 was assessed by the med tech, and no visible injuries were noted, and under the ‘Immediate Prevention of Re-occurrence’ section of the report, it states that R1 will be reminded to use the signal pendant when assistance is needed, and R1 will be checked on an hourly basis. On 10/25/2021 at 10:00 a.m., the LPA interviewed the Reporting Party (RP) in reference to the falls sustained by R1, and asked if R1 had sustained bruises, or injures due to the falls, and if R1 had been seen by a physician due to the falls? RP stated that R1 had not sustained bruises or any type of injury, nor had been seen by a physician. On 10/26/2021, at 2:00 p.m., the LPA interview the ED about the falls sustained by residents and the plan of action to ensure residents are safe. The ED stated that the beds have motion sensors that signal when residents get off the bed, and that the signal pendants work, but because the residents may suffer form memory loss, they may not remember to use the signal system, when assistance is needed. On 10/26/2021, at around 12:55 p.m., the LPA interview staff about the time frame to respond to the pendant calls? The staff stated that it usually takes five minutes from the time they receive the signal, but depending on the calls received at the same time, it may take longer than five minutes.

Based on the information gathered, interviews, and records review, the multiple falls of R1 while in care happened while resident was under care. Two of the falls documented in the in-house Incident Reports stated that the resident was attempting to get the pendant to call staff. Therefore, the allegation is deemed as SUBSTANTIATED at this time.