Complaint Investigation Report

dates: 10/2, 10/6, 10/9, 10/13, 10/24, 11/5, and 11/9. R1’s fall on 11/9, resulted in a fractured shoulder and laceration on their head. Progress notes on 10/31, state that there was no catheter output for all of NOC shift. There is no documentation that R1’s family or physician was notified. R1 was later sent to the hospital where their hospital records note that more than 854 mL was drained.

R1 was followed by Freedom Home Health, who had provided them with regular nurse visits. While the facility was responsible for draining the catheter, any medical interventions related to the catheter was provided by Freedom Home Health. However, because a catheter is considered a restricted health condition, the facility was required to provide training for all staff regarding R1 and their catheter care. There is no documented evidence that the facility staff were provided this training.

Based on the information detailed above, LPA finds that both these allegations are substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Due to R1's fall which resulted in a fractured shoulder, a $500 civil penalty for serious bodily injury will be issued. This civil penalty will be issued at a later date due to technical issues.

Deficiencies cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.