Complaint Investigation Report

On October 27, 2024, R1 tripped while getting up from their bed and slipped on the side of their bed. R1 sustained a scrape to their right arm and shoulder. The facility notified R1’s family and nurse practitioner.

On November 04, 2024, R1 fell while walking out of their room. During the incident, R1 hit their head on a bench in the hallway. The fall was witnessed by a nearby caregiver. Staff called 9-1-1. R1 was later diagnosed with a subdural hematoma which was determined to be non-operative. R1 was discharged back to the facility after a couple of days of observation in hospital. R1’s family and nurse practitioner were notified of the incident. On November 07, 2024, the resident was seen by their home health nurse who notated the resident got multiple abrasions on the right side of their eye socket and a black eye.

On November 27, 2024, while being assisted by their 1:1 caregiver, R1 tripped and sustained a fall while walking into the facility. Paramedics were called by staff and R1 was assessed to not require further medical attention. Two witnesses interviewed later reported caregivers found teeth on the floor and discovered R1 had missing teeth. The facility notified R1’s family and nurse practitioner.

On December 11, 2024, R1 sustained an unwitnessed fall in front of their recliner. Staff observed R1 had two small scratches on their back but did not complain of pain and was observed able to walk. R1’s family and nurse practitioner were notified and first aid was applied.

On December 13, 2024, R1 sustained an unwitnessed fall next to their bed. Caregivers heard R1 yelling for help. R1 did not push their pendant or complain of pain. Facility staff monitored R1 for any further changes of condition. 9-1-1 was not called however facility notified resident’s nurse practitioner.

On December 18, 2024, R1 sustained a second fall while being escorted to the bathroom by a caregiver. Per interview with caregiver 1 (C1) they were closing the front door and trying to get into the bathroom when R1 fell. C1 observed R1 fall toward the shower. C1 called the facility Residential Care Director (RDC). Per interviews conducted, R1 was bleeding from their shoulder and lip. 9-1-1 was called and tended to R1’s injuries on their arm. R1 was admitted to St. Joseph Hospital Orange where they were diagnosed with acute on chronic intracranial subdural hematoma. Neurosurgery was consulted and recommended nonoperative management. Resident remained hospitalized until December 22, 2024.