Complaint Investigation Report

The department interviewed care staff, in which they stated R1 requires minimal assistance with showering, toileting and dressing. R1 is considered non-ambulatory and uses a walker to get around the facility. R1 was provided a call button which they wore around their neck to call for help if needed. Per the facility call button records, there is no record of R1 pressing their call button on 8/28/21. R1 attempted to use the restroom on their own without pushing their call button, resulting in R1 sustaining the fall.

Per care staff, R1 is instructed to punch their call button for any services they may need assistance with. Per facility call button history, R1 understood this and would push their call button daily if not multiple times a day. Although R1 did sustain a fracture while in care, the department is unable to determine if it was due to facility neglect. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.

The department investigated allegation, “Staff are not responding to residents call button in a timely manner.” On 8/28/21, R1 sustained an un-witnessed fall in their bathroom resulting in them fracturing their left femur. R1 was found by care staff and immediately sent out to the emergency department for medical treatment.

The department reviewed call button history for R1 for the past six months, from February 2021 to August 2021. The call button history showed R1 pressing their butt on daily if not multiple times a day, which shows R1 had a cognitive understanding on how to operate the call button. Based on the call button records, R1 did not push their call button on 8/28/21 to call for help. Call button records show which room is requesting assistance, and at what time and on what date.

LPA interviewed 5 clients in care in which they stated at times caregivers arrive in a timely manner once they push their button and at times it takes over 30 minutes to respond.