Complaint Investigation Report

At this facility, there are multiple buildings identified as cottages. Within R1’s cottage, there are multiple apartment-like bedrooms with their own bathroom. Each cottage also has common areas which include kitchens shared by all residents. During staff interviews, it was reported that on 04/17/2024, R1 was assisted by staff to toilet in their apartment. Staff assisting R1 left R1 on the toilet, exited R1’s apartment, and went to the cottage’s kitchen to get water for R1. It was further reported the staff told R1 to stay seated on the toilet. It was estimated the staff was gone approximately 1-2 minutes. As staff made their way back to R1’s apartment, they heard R1 yelling for help. R1 was found on the floor. Staff called for medical attention. Charting notes dated 04/17/2024 with a time entered as 8:51pm revealed the following note: R1 had unwitnessed fall in their bathroom. R1 reported they wiped themselves with no caregiver present and fell. R1 refused for 911 to be called. The Serious Incident Report (SIR) dated 04/17/2024 revealed the date of the incident was 04/17/2024 and the time of incident was 6:55pm. It reads R1 got up to wipe themselves with no caregiver present and fell. R1 had red mark on their forehead. R1 refused for 911 services to be called.

In the interview with R1, R1 reported experiencing a medical event and was administered their prescribed medication (M1). Charting note dated 04/17/2024 with a time entered of 3:55pm revealed the following note: R1 experienced the medical event and was given M1. R1 reported being especially concerned about being left alone in the bathroom that day. R1 said the medication “puts me out like a light.” R1 added the sedating effects M1 can last 5-7 hours, depending on how well R1 slept the night before. Because of the sedation, R1 was unable to estimate how much time had passed between the medical event and when R1 escorted to the bathroom by staff. Once R1 was positioned on the toilet, R1 reports they told S1 to stay with them. R1 added they had to remind all caregivers about staying with R1 after M1 is provided. R1 reported staff assisting them, left the room completely and did not say anything to R1 about why staff was leaving, how long they would be gone, nor did staff ask R1 to wait on the toilet until staff returned. When staff did not return after a period of time, R1 decided to try to wipe on their own. R1 can generally wipe on their own but tends to need help from the staff to get their pants and briefs pulled up.