Complaint Investigation Report

sustain a fall that residents are not on the floor for long. During the investigation LPA reviewed documents including the Unusual Incident/Injury Reports (UIIRs) dated 10/24/23 for R2 and R3. Per UIIR R2 and R3 had an unwitnessed fall and were taken to the Emergency Room for evaluation. During the course of the interviews ED stated that she is not aware of an alleged fall where the resident was laying on the floor for over two hours. Per ED R2 and R3 did not wait on the floor for long and reported that the highest staff response time could be 30 minutes.

Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED.

LPA Ramirez conducted an exit interview with ED Chon, and a copy of this report was provided to the facility.