Complaint Investigation Report

9099C-1.. Per the physician's report,(R1) can be confused/disoriented, exhibit inappropriate behavior, including sundowning but is able to communicate needs and follow instructions.

Allegation: Resident was left on floor for an extended period of time. The allegation states on the evening of 11/10/24 (R1) had a fall in their apartment and waited an hour and a half for staff to assist, after pressing their pendant. (R1) then called their family member, and they were on and off the phone while (R1) was on the floor. The facility finally responded but it was a caregiver that (R1) does not like so they refused care until a Med-Tech came to help resident off the floor.

Staff (S1) confirmed she worked on the “pm” shift (2:00 pm- 10:30 pm) on Sunday, 11/10/24, and stated after dinner, she "moved (R1) from the dining room as they were being very verbal, cussing at me", and took (R1) to their room and offered them water. (R1) refused, was mad and then locked their door. (S1) returned to (R1's) room 15-20 minutes later, around 7:10-7:12 pm, and asked (R1) if they were okay and offered their scheduled dose of insulin, which (R1) said "No" to. (S1) stated that around shortly afterwards, she got a call on the house phone from (R1's) family member that (R1)was on the floor in her room. (S1) stated she checked on (R1) again around 7:20-7:30 pm, and "saw them on the floor". (S1) stated (R1) fell as they tried to transfer them self from their wheelchair to their bed and fell, and she and two other staff, (S4) and (S2), assisted her. (S1) asserted that "it was 10-15 minutes maximum that she was on the floor", and (R1) will "regularly push the call button if they are upset" and doesn't hesitate.

A second staff (S2) confirmed he was working on the "pm" shift on Sunday, 11/10/24, when resident (R1) was found on the floor. (R1) commented "(R1) doesn't like men to help her, and I think Med-Tech, (S1), called me to help pick (R1) up, and we went to her room. (S2) confirmed that he, (S1) and another caregiver, female, assisted (R1) to get up from the floor. (S2)stated staff "do rounds, I have no idea how long they were on the floor, but it was not (3) hours, “adding, "I think they pressed their pendant" which goes to all staff's pagers.

A third staff (S3) stated on 11/19/24 that she works "pm" shift but did not work on 11/10/24. (S3) explained that around 7:30/8:00 pm, caregivers will begin to put residents to bed, and staff will assist (R1) in the bathroom, change them into their pajamas, take off their dentures, comb their hair and put them to bed. (S3) stated staff will check on (R1) and all other residents again from 8:30/9:00 pm to make sure residents are in bed before 10:00 pm, when the shift change occurs. *cont on 9099C-2..