Complaint Investigation Report

Per review of Unusual Incident/Injury Report for 09/24/2021 it was reported R1 was found on the floor by staff and was assessed, R1 did not complain of pain and was able to ambulate with walker. Per report both R1's physician and responsible party were notified. It was also reported that resident was placed on alert charting and service plan was updated.

Per review of Unusual Incident/Injury Report for 11/18/2021 it was reported R1 was found in the bathroom floor after R1 attempted to use the restroom. Per report R1 hit her head and 911 was called and R1 was assessed by paramedics but refused transfer to the hospital. Per report paramedics did not note any bumps on R1's head. R1 was placed on alert charting and mention of physical therapy and occupational therapy to continue to work with R1. R1's family and physician were notified and service plan was updated.

Per review of Unusual Incident/Injury Report for 04/18/22 it was reported R1 reported to staff that they had chest pains and R1 was sent out to the hospital. R1's family and physician were notified. R1 was admitted to the hospital until 04/21/2022 diagnosis was pneumonia, R1 was notified needed a stent replacement but declined surgery.

Per review of Unusual Incident/Injury Report for 04/21/2022 it was report R1 was found on the floor next to their bed by staff. R1 was noticed to have blood and bruised left eye and hand. 911 was called and R1's family and physician were notified. R1 was admitted to the hospital and returned to the community on 04/22/2022. Per report a 1:1 caregiver was put in place following hospital discharge.

Per Progress notes dated on 05/25/2022 it was reported R1's 1:1 caregiver notified staff that R1 had fallen and staff went to assess resident, during assessment R1 had purple lips, 911 was called. It was reported that staff notified R1's family and physician. R1 was admitted to the hospital until 05/28/2022.

R1 was admitted to hospice on 06/09/2022.

Per review of Unusual Incident/Injury Report for 07/17/2022 during rounds staff went to open R1's door but could not due to R1 blocking the door. Per report staff was able to access the resident's room via patio door. 911 was called and resident was taken to the hospital. R1's family and physician was notified.