Complaint Investigation Report

Resident sustained fractures due to staff neglect

It was alleged that due to neglect/lack of care and supervision resulted in Resident 1 (R1) falling on 01/12/2022 and sustaining two femur fractures.

During the course of the investigation LPA interviewed R1, witnesses, and prior Facility Director Heather Myers regarding R1's fall and injury on 1/12/2022 which occurred in their room and was unwitnessed. Witness statement indicated that R1 used their pendant to call for assistance to go to the bathroom. R1 got up on their own when staff did not respond in a timely manner, and R1 fell to the floor breaking both femurs.

R1 stated they got out of bed on their own and went to the bathroom using their walker. When R1 was finished on the toilet, they stood up to get their walker and fell to the ground, breaking both of their femurs. R1 stated they could not recall using their pendant to call for staff assistance when they had finished using the toilet, nor when they were on the ground after the fall. R1 stated they screamed for help and staff arrived quickly.

LPA reviewed the Unusual Incident/Injury Report related to this incident which states R1 told the Med Tech Staff 1 (S1) that R1 rolled out of their bed injuring their legs. LPA spoke with Heather Myers who was the Facility Director on 1/12/2022. Heather stated that R1 was brought a daybed and R1 would place their ankles under the foot rail. On the evening of 1/12/2022, it is believed R1 broke their legs when rolling out of bed with their ankles caught in the bedrail of the daybed. Heather stated when staff found R1 in their room, they were lying next to their bed still wrapped in their blankets. R1 was assessed by facility staff who immediately called 911 and notified a family member. R1 was transported to the hospital for further evaluation and diagnosed with femur fractures in both legs. S1 does not work at the facility any longer and LPA’s attempts to contact them were unsuccessful.

Based on interviews and document review, there was no evidence to corroborate the allegation of neglect by staff resulting in R1's fall and injury. Therefore, the allegation of Neglect/Lack of Care and Supervision of Resident R1 falling on 1/12/2022 and sustaining two femur fractures will be unsubstantiated.