Complaint Investigation Report

Allegation: Questionable death- Unsubstantiated

A review of R1’s death certificate listed that they passed away in May 2025 due to a Traumatic Intracerebral Hemorrhage due to a ground level fall with a time interval between onset and death listed as months. On 02/13/2025, R1 sustained an unwitnessed fall and was sent to the hospital. Medical records show a “possible small left frontal Intracerebral Hemorrhage.” No fractures or other injuries were documented in the medical records. R1 was placed on hospice following this incident. Conflicting statements were provided on whether R1 sustained additional minor falls after 02/13/2025 and while being on hospice.

Deputy Coroner (DC) stated that the multiple falls made the brain bleed “a little worse each time.” DC stated this is “common in older people though, especially with R1 being 100 years old.” DC was not concerned that R1 may have passed away due to neglect by the facility staff. DC stated there is “no way” of knowing which fall contributed to R1’s death. It is unclear if the major fall on 02/13/2025 was as a result of staff neglect. Prior to that, R1 had only sustained one fall at the facility on 05/20/2024 and did not require any specialized fall interventions or special checks.

Allegation: Resident sustained multiple falls resulting in serious bodily injury- Unsubstantiated

Records revealed that R1 resided at the facility for approximately two years and sustained two major falls during that time. The first fall occurred on 05/20/2024 and resulted in a skin tear. The second fall occurred on 02/13/2025 and resulted in a “possible small left frontal Intracerebral Hemorrhage.” No fractures or other injuries were documented in the medical records.

Records and interviews support that R1 was not a fall risk and was primarily independent. R1 did not require specialized checks or specific fall measures. Conflicting statements were provided on whether R1 sustained additional minor falls while residing at the facility indicating need for specialized fall prevention interventions. R1 sustained an additional fall on 04/04/2025 while on hospice. Hospice care staff were notified and directed the facility staff to not send R1 to the hospital due to no injuries seen.

Based on this information, these allegations are UNSUBSTANTIATED . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

Exit interview conducted. A copy of the report and appeal rights left at the facility.