Complaint Investigation Report

Regarding the allegation, “Staff did not meet reporting requirements” it was alleged the facility failed to meet the mandated reporting requirements after a resident suffered a broken leg from a fall in the facility. It was further alleged that a different resident had falls on 06/13, 06/14, 06/16, 06/18 and multiple visits to the emergency room that were also unreported. The residents were identified by their room numbers.

The resident identified in the allegation who allegedly had a broken leg was identified as Resident 1 (R1). There were a total of five (5) staff interviewed. One (1) of five (5) staff interviewed was unable to recall any resident breaking their leg in the facility. The remaining four (4) of five (5) staff interviewed reported, R1 never broke their leg in the facility. LPA attempted to conduct an interview with R1 to inquire whether they suffered a broken leg while at the facility. However, R1 was unable to participate in the interview. LPA also made attempts to contact R1’s responsible party but was unsuccessful.

LPA reviewed Unusual Incident/Injury Reports (LIC 624s) regarding Resident 2’s (R2) unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 which were reported to Community Care Licensing (CCL) timely. The reports documented 911 was called each time, and each time R2 was transported to the hospital for further evaluation. The reports also indicated R2’s responsible party and primary care physician were notified. LPA made contact with R2’s responsible party who reported R2 has since passed away. The responsible party reported that facility staff notified them of multiple falls R2 experienced in the facility and was aware R2 was sent to the hospital for evaluation. However, the responsible party was unable to recall exact incident dates and therefore was unable to confirm whether the facility reported every fall to them since R2 exhibited memory loss and RP was not always in the facility. Five (5) of five (5) staff interviewed reported the facility follows mandated reporting requirements and activates emergency services each time a resident has an unwitnessed fall or incident. Five (5) of five (5) staff interviewed added they have never suspected staff abuse or neglect led to the resident incidents and/or falls which include any incidents involving R1 and R2. It was reported that this is why the incidents were reported to CCL but not the Long-Term Care Ombudsman nor Law Enforcement.