Complaint Investigation Report

On 8/7/24, Licensing Program Analysts (LPAs) Kevin Mknelly and Graham Gunby, interviewed the Administrator, Abigail Budoc who told LPAs that Administrator had recently left the facility and had an appointment at 4 PM. Administrator stated that they had been told by the hospice agency to always call them first for resident concerns. Administrator acknowledged that they also trained S1 to this practice. The Administrator understood from their interview with S1 following the fall, that S1 heard R1 fall at approximately 4:30 PM on 8/4/24. S1 went to R1 immediately. Administrator told LPAs that S1 left R1 in the position R1 had fallen and that when family arrived, they moved R1 to a sitting position on the floor against R1’s bed.

LPAs, accompanied by Administrator, observed the placement of R1’s bed, a walker, a commode in R1’s room and the dresser on which R1 had hit R1’s head when R1 fell. Administrator stated that R1 needed cues to use their walker and that R1 independently used the commode when needed (approximately 5 feet from R1’s bed to the commode). It is unknown if R1 had used their walker. From R1’s reported potion on the floor, R1 may have fallen from near the commode to R1’s right and R1 hit their head on the dresser 4-5 feet to R1’s right.

LPAs interviewed S1 on 8/7/24. S1 reported that Administrator had worked at the facility in the morning. S1 was the lone caregiver, for three residents, at the time of R1’s fall. S1 stated that they had observed R1 to be sitting up on R1’s bed as S1 went to another resident’s room adjacent to R1’s. S1 heard a loud noise from R1’s room and immediately went to R1. R1 appeared to be in the process of removing their pants at the time of their fall on 8/5/24. R1 was found on the floor and bleeding from a laceration to R1’s head. S1 stated they moved R1 to sitting on the floor by R1’s bed and applied ice and a cloth to R1’s head injury. S1 showed LPAs S1’s phone that showed S1 attempted to reach hospice and the administrator by phone and text between 4:29 PM on 8/4/24 and 5:09 and that Admin responded by text at 5:47. S1 stated that prior to this incident, S1 had been directed that when incidents happen to residents on hospice, staff are to call Hospice instead of 9-1-1.