Complaint Investigation Report

“Staff neglect/lack of supervision resulted in a resident sustaining a serious injury” - Resident 1 (R1) was admitted to the facility in June 2023. Facility reported that on 7/18/2023, R1 had decreased appetite and was having a hard time standing so R1’s Responsible Party was called, came to the facility and had R1 sent to the hospital where they were diagnosed with a left “displaced intertrochanteric hip fracture.” Per interviews with staff, R1 did not have an observed fall, however, 4 of 8 staff interviewed noted R1 complaining of pain, refusing care, and not feeling well on 7/17/2023. Interviews and multiple reports revealed that by 7/18/2023, R1 was complaining of pain and was not able to stand. Per interview and medical record review, R1’s leg was observed to be swollen on 7/18/2023.

Review of R1’s medical records dated 07/18/2023 noted that facility staff informed emergency personnel that R1’s leg was observed to be swollen since 07/17/2023. Per report, R1 had complained of hip pain on 07/16/2023 but was observed to still be able to bear their own weight. Review of facility’s 24-hour log dated 07/15/2023 and 07/16/2023, showed staff did not note any changes observed for R1. Facility reported that R1 had an unwitnessed fall on 10/08/2023, which staff responded to when they heard R1 calling for help. Per report, R1 was “visually assessed” by staff because R1 did not want to be touched. Two staff members assisted R1 into their wheelchair and then staff called the Administrator who called R1’s Responsible Party. R1’s Responsible Party arrived at facility and requested that R1 be sent to the hospital. R1 was sent to the hospital where they were diagnosed with a right “femoral neck fracture” per obtained medical records dated 10/08/2023. Review of Facility’s 24-hour log dated 10/08/2023, did not note any changes observed.

Review of R1’s Physician’s Report dated 06/08/2023, stated that R1 had a dementia diagnosis, had auditory, visual, and motor impairment, and needed assistance with their Activities of Daily Living (ADLs). Review of R1’s Needs and Services Plan, dated 06/24/2023, stated that R1 used a walker and needed help with ambulating and transferring. Review of R1’s Needs and Services Plan dated 06/24/2023, stated that R1 used a walker and required stand-by assistance with ambulating and transferring. Staff interviews conducted reported that they do not look at or have access to resident files and rely on facility management to inform them of resident care needs. Facility staff were unable to identify fall interventions to mitigate R1’s risk for falls. Interviews stated that interventions with R1’s Responsible Party were discussed but nothing was put in place. Review of facility records showed no indication that a care conference was held or that a reappraisal was completed . Review of Facility’s documentation indicated that in the event of a fall or post-fall assessment, staff are to report, access for serious injury and current condition, obtain fall history, assess environment, assess future fall risk, and analyze the fall and create a post fall action plan. Review of Facility’s Program Plan for “Policy and Protocol for Emergencies” stated the following: “Any and all medical emergencies that require assistance will be handled by first calling 911, notifying the resident’s physician, following with communication with the family or responsible party.