Complaint Investigation Report

with staff, while R1 was receiving assistance with ADLs on 6/18/23, R1 gestured to staff of pain in their left side. Staff indicated that they did not observe any bruises or any other injuries. Staff indicated that they did not witness any incidents prior to R1 gesturing that they were experiencing pain. Unusual Incident/Injury Report and interviews with staff indicated that R1’s responsible party was notified regarding R1’s complaint of pain. Staff indicated that they informed R1’s responsible party that they would like to send R1 to the hospital to be evaluated. Staff indicated that R1’s responsible party instructed the facility that they would schedule an appointment with R1’s primary care physician (PCP). According to Unusual Incident/Injury Report and interviews conducted, R1 was seen by their PCP on 6/22/23 and R1 was discovered to have fractured ribs on their left side.

Medical records indicated that R1’s responsible party contacted the hospital, on 6/18/23, requesting a checkup for R1. R1 was taken to their scheduled appointment on 6/22/23. Medical Records indicated that R1 had complained of pain and no fall was reported. R1 was found to have minimally displaced left anterior lateral seventh, eighth, ninth, and tenth rib fractures.

Interviews with residents, who had recently sustained falls at the care home, indicated that staff go out of their way to ensure residents are given medical treatment, when needed. No residents had any complaints regarding staff and the care being provided.

Allegation: Resident was left on floor for an extended period of time.

Interviews with ED and multiple staff indicated that R1 was not a fall risk and had no incidents of falls while at the care home. Interviews indicated that R1 was good at walking. Interviews also indicated that R1 did not require any mobility devices. Progress notes dated 5/15/23-7/27/23 indicated on multiple entries that R1 was walking independently and there were no notations of R1 falling while residing at the care home. The facility did not have any incidents indicating R1 had any falls.

Allegation: Staff do not communicate resident's incidents to responsible party.

Interview with ED indicated that R1 only had one incident while residing at the care home, which occurred on 6/18/23. The 6/18/23 incident was regarding R1 gesturing to staff that they were experiencing pain in their left side. Unusual Incident/Injury Report indicated that staff contacted R1’s responsible party, as well as the responsible party would set up a doctor’s appointment for R1. Interview with S1 indicated that when R1 was

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