Complaint Investigation Report

Records further indicate that based on R1's previous fall, R1 was put on hour checks to ensure R1's safety. After R1's fall on 08/09/2021, it was determined at the hospital that R1 needed a higher level of care than what the facility could provide and R1 did not return to the facility.

The allegations are substantiated however, no citations are issued. The facility put hourly checks in place to monitor R1 and there is no evidence that R1's fracture was due to the negligence of the facility. In addition, once R1 was identified as needing a higher level of care, R1 was relocated.

An exit interview was conducted and a copy of this report was given to Lori Berkeley