Complaint Investigation Report

90099C-1.. Allegation: Facility has insufficient staff to meet the care needs of the residents. The allegation states the facility did not provide sufficient staffing which resulted in (R1) falling, breaking their hip and requiring a wheelchair.

The Administrator confirmed that (R1) did not have a fall in January 2026, when the complaint was filed, but had a fall in October 2024 which resulted in a change in condition. The Administrator confirmed (R1) still uses a wheelchair, has been on fall management following the fall on October 9, 2024, and (R1) was sent to the Emergency Room after this fall due to complaining of pain. The incident report completed and submitted to the Department on October 11, 2024, notes (R1) was sent to the Emergency Room (ER) due to (R1) complaining of “lower extremity pain with movement”.

The charting notes state that on October 9, 2024 (8:04 pm), (R1) had an unwitnessed fall in the common area/dining room and that the family member was contacted and requested to be notified if (R1) needs to go the ER. The subsequent entry indicates that (R1) was sent out to the Emergency Room on October 10, 2024 (8:14 pm) per the family member’s request due to resident stating they were in pain and not being able to move their left side. (R1) returned from the hospital on October 15, 2024 (6:00 pm).

The LVN stated she was not at the community when (R1) fell on October 9, 2024, as it occurred around 8:00 pm after her shift ended. Two Med-Tech staff who work “am” shift stated they didn’t recall the fall (R1) had on October 9, 2024 (8:00 pm) but recalled (R1) being at the hospital and then returning in a wheelchair. These staff indicated (R1) has had no other serious falls or any pressure wounds. A family member stated that "(R1) wasn't using a walker as a habit" which contributed to the fall, and "staff were instrumental in getting (R1) to recover better". This family member commented that she observed there to be sufficient staffing each day of the week when visiting (R1).

Staffing schedules reflected (4) care staff and (1) Med-Tech scheduled on am/pm shifts and (3) care staff scheduled on NOC shift for approximately (32) residents residing in MCU.

The care plan in place at the time of the fall indicated that Resident is at risk for falling and requires staff observation to promote safety, but does not require use of an assistive device. The care plan was updated on 11/14/2024 and reflected an increase in care (R1)requires total assistance with dressing, feeding, toileting, transferring, escorting (wheelchair). Remains on Fall Management.

Based on information obtained, the department finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation 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.