Complaint Investigation Report

R1 had history of falls from December 2024 through July 2025. R1 had total of seven (7) reported falls during that time. R1 was sent to Hospital #1 on March 31, 2025, by R1’s physician’s order for altered mental status and frequent falls. R1 was hospitalized until they were discharged to a skilled nursing facility on April 23, 2025. R1 was sent to Hospital #2 after being found unconscious on August 10, 2025. R1 passed away on August 10, 2025, while under hospice care.

The Department’s review of medical records from Hospital #1 revealed that R1 was observed with bruises on left upper hip, right lower hip, and multiple bruises in upper and lower extremities in various stages of healing. R1 was also noted to be confused, not able to follow commands, frequently trying to get out of bed, pulling on IV lines, agitation, yelling and screaming. Those conditions required R1 to be put on soft restraints on upper and lower extremities. R1 remained restrained until they were discharged on April 23, 2025.

The Department’s review of records revealed that staff did not conduct reassessment and update care plans after seven (7) recorded falls. Five (5) out of those (7) falls occurred in March 2025. R1’s bruises observed by medical staff at Hospital #1 were consistent with those five (5) falls that occurred in March 2025. Even after those falls, staff did not maintain updated assessments and care plans reflecting R1’s declining condition and increased fall risks.

Based on records review, the evidence found during the Department’s investigation met the preponderance of evidence standard. Therefore, this allegation is substantiated.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation was issued.

An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099-D and Appeal Rights.