Complaint Investigation Report

Continued from LIC9099A...Regarding the allegation of appropriate measures were not put into place for resident who was a fall risk. Per Reporting Party, R1 was found on the floor at least two different occasions by private caregivers after R1 had slid out of the bed, their head and shoulders on a mat and the rest of their body on the cold floor with no injuries reported. Staff were unaware that R1 had fallen because they were not checking on R1 as they should have due to R1 was a fall risk. Per Reporting Party, R1 had a fall risk bracelet on their arm, but at some point, somebody at the facility took that bracelet off and it was placed on a table. Staff had lowered R1’s bed the lowest that it could go to the floor, and mats were placed around R1’s bed to address R1's fall risk. Based on records review of facility communication log dated 12/26/22 at 5:16am and 12/30/22 at 8:29pm confirmed that R1 had an un-witnessed fall. On 12/26/22 at 5:16am, R1 was found by facility staff lying on their back on the floor next to their bed, but denies hitting their head, facility conducted assessment of the resident, no injuries or skin discoloration were noted, facility notified R1’s responsible party and hospice about the incidents. Also, bed was set to the lowest position and floor pads were placed. On 12/30/22 at 8:29pm, R1 was found by facility staff facing up lying on the floor on top of their pad next to their bed. R1 was assessed, no injuries were noted and was assisted back to bed by 3 facility staff, facility notified R1’s responsible party and hospice about the incidents. Per incident report, both incidents contributing factors were R1’s balance impairment, poor safety practices and history of falls. Per hospice records obtained dated 12/25/22, R1 had an anxiety and/or agitation problem that a goal was set to minimize them with medication regimen in place to prevent fall risk while agitated. Also, R1 was assessed as a fall risk person and both incidents were noted in hospice daily care notes. Facility staff was instructed to monitor R1, safety checks, bed safety. However, LPA reviewed incident and death report logs for resident (R1) who passed away on 1/4/23 which were not reported to CCL within 7 days of incident. This deficiency will be addressed in a case management for reporting requirements. During confidential interviews conducted with staff that works in the Health and Extended Care Center (Kronborg), upon arrival to this area, Wellness Director removes any fall risk bracelet from resident’s arms because all of them are considered fall risk due to their mobility limitations, and staff is set to conduct round checks every two hours and if any resident need help sooner, residents will pull their call light system and staff will respond to their call within minutes. LPA obtained call light system response for both incidents that confirmed that R1 was assisted within minutes after having falls. A finding that the complaint allegation appropriate measures were not put into place for resident who was a fall risk is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continue on LIC9099C...