Complaint Investigation Report

Hospice records showed that the wheelchair used by R1 on 12/18/23 was newly provided and was delivered without the proper cushion for positioning.

Interviews found that 4 staff were present conducting a shift change briefing and that R1 was seated in their wheelchair approximately ten(10) feet away, partially obscured by a post, at the time of R1's fall . According to staff statements, R1 had not made any typical vocalizations of distress or discomfort prior to staff hearing a fall had occurred. When the briefing took place, statements indicate R1 to be seated nearby quietly and not in need of assistance.

Evidence suggests that R1 had moved unexpectedly and without warning resulting in an accidental fall. R1 was not requiring 1:1 staffing. Staff present responded immediately after the fall to provide first aid. Hospice was notified promptly and R1 was seen by hospice 12/18/23.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.