Complaint Investigation Report

It was alleged that on July 7, 2021, R1, who is bedbound and requires total care, was brought to the hospital, diagnosed with a left distal spiral femur fracture, and facility staff were unable to explain how R1 sustained the fracture. LPA interviewed AD who stated that on July 2, 2021, R1 was seen by their doctor at the facility who found no issues with R1, then on July 7, 2021, staff noticed swelling on R1’s knee and took R1 to the hospital where they were diagnosed with a fracture, and AD does not know how R1 sustained the fracture. Per AD, R1 is sensitive to movement, so the facility uses two staff to transfer R1 using a Hoyer lift, and due to the risk of bed sores R1 is repositioned every two hours. AD stated that no bruising or visible injury was observed at the site of the fracture and that R1 had a long-standing small fracture in the same location as the fracture diagnosed on July 7, 2021. LPA attempted to interview R1, but R1 is non-verbal. LPA inspected the facility, conducted health and safety checks on R1 and the other four residents, and observed no health and safety issues. LPA interviewed the other four residents, two of whom were unable to participate in the interview, and two of whom reported no concerns with the care provided at the facility. LPA interviewed three staff who provided care to R1, none of whom were able to identify any falls or injuries that could have caused the fracture. Review of R1’s medical records revealed that R1 has a history that includes a chronic left humerus fracture and chronic hip/pelvic fractures. Per R1’s medical records, on July 7, 2021, R1 was diagnosed with an acute, comminuted displaced fracture of the femoral diaphysis, R1 was noted to have weakened and brittle bones, and follow up was recommended to exclude a pathological fracture resulting from weakened bones that can easily break after a minor injury that would not normally cause serious damage. Per a letter from R1’s doctor, R1’s bone condition places R1 at risk for fractures after low energy trauma including twisting and/or bumping the extremities while seated in their chair.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.