Complaint Investigation Report

R1 moved into the facility on June 6, 2022. R1 was diagnosed with Hyperlipidemia, Dementia, Hyperparathyroidism, gout and had a pacemaker implant. R1 was reported to be ambulatory, could independently transfer to and from bed and did not require the use of a walker or wheelchair at the time of move in. R1 did not require assistance with most tasks. The fall risk evaluation showed R1 was a moderate fall risk and no written service plan for prevention of falls was indicated. On January 11, 2023, around 10:30 am R1 was being visited by their family. R1’s responsible party reported that R1 appeared to be in pain and observed a bruise on R1’s thigh. R1’s resident care notes dated January 8, 2023, list a bruise to R1’s thigh that may have been self-inflicted. Staff 2 (S2) reported that they noticed bruising on R1’s thigh around January 4 or January 5, 2023, and it was reported to R1’s responsible party. The name on the entry is illegible. Staff 1 (S1) reported R1 appeared fine all morning on January 11, 2023. R1’s responsible party reported that staff were unable to provide any history about the bruise on R1’s thigh. At 7:00 pm R1’s responsible party returned to the facility to visit R1. R1’s responsible party reported that staff was preparing R1 for bed and R1 was screaming. R1’s responsible party reported that that R1’s bruise was now swollen and R1 appeared to be in pain. R1’s responsible party reported that they asked Staff 1 (S1) to call 911 but S1 did not feel it was necessary to call 911 but they did so because of the request. R1 was transported to St. Jude Medical Center by ambulance. R1 was diagnosed with a distal interprosthetic fracture, a break in the femur between a hip replacement and a knee replacement. St. Jude medical records for R1 shows the attending physician noted, the fracture was of unclear chronicity (the onset cannot be precisely determined) and the injuries sustained appeared to have occurred two to three weeks earlier. R1’s responsible party reported that R1 had been unable to successfully transfer or bear weight since the beginning of January 2023. Facility staff could not corroborate this report. On January 13, 2023, R1 had surgery to repair their fracture. R1 was discharged from the hospital and moved to a skilled nursing facility for rehabilitation. R1 moved to another assisted facility after being discharged from the skilled nursing facility. R1 passed away on May 5, 2023, under hospice care. It is unknown how or when R1 sustained their fracture and the bruise on R1’s thigh was never addressed until January 11, 2023, when R1’s responsible party requested R1 be taken to the hospital. R1 was diagnosed with a distal interprosthetic fracture on January 11, 2023, and the medical records show the fracture was 2 to 3 weeks old.