Complaint Investigation Report

9099C(1)..Resident moved to the facility on/around 2/27/22. Pre-appraisal documents that resident is visually impaired and uses a walker and service animal for balance due to a diagnosis of ataxia and does not need special observation or night supervision due to confusion, forgetfulness and/or wandering. Resident’s care plan was updated on 4/22/22 due to a change in condition - all service points allocated to additional housekeeping and pet care (walks 3x/day). Resident has resided in the Assisted Living Unit (ALU) since moving in and resident's physician's report, dated 2/27/2022, notes that resident does not have a diagnosis of Dementia or Mild Cognitive Impairment.

Allegation: Staff failed to respond to resident’s call button.

Allegation states that staff did not respond timely to resident’s call assistance button pressed initially after resident fell, and repeatedly throughout the night, until 5:30 am.

Resident (R1) stated in an interview that she fell on 4/20/2022 at approximately 10:45 pm and was able to get up within 10 minutes from the floor by herself and "was able to move her legs and arms and had her phone handy" and called staff for assistance. Resident stated she also has a lanyard pendant and wears it day and night", and after falling on 4/20/22, she kept pushing the pendant and calling every 10 minutes throughout the night, until 5:45 am when staff (S1 and S2) finally showed up. Resident explained she "doesn't know why staff never answered" and that 15 minutes is the normal response time and stated that staff gets so many calls they can't tell if they are "new calls or old calls" coming in and the pendant "should be for emergency use but is used indiscriminately".

Staff (S1 ) who worked during the NOC shift on 4/20/2022, stated that around 10:15 pm she and Med-Tech staff (S2) walked by resident's door as they were transitioning to do rounds in Memory Care and heard what sounded like resident talking on the phone. S1 stated that resident (R1) is not checked on regularly throughout the day or night, based on her care plan and only residents in the Memory Care Unit are checked on regularly. S1 stated she noticed her pager went off around 4-4:30 am on 4/21/2022 for resident's room and responded very promptly, as she does everytime the pager goes off. S1 stated that her pager has always worked correctly and when she starts a shift, she makes sure to clear the pager so there are no calls pending from the prior shif. S1 confirmed she received calls from other residents during her shift from 4/20/2022- 4/21/2022 and always carries a pager with her during her shift.