Complaint Investigation Report

Allegation: Resident sustained injury, fracture to spine, as a result of a fall: Substantiated

The department conducted a records review, staff and residents’ interviews to investigate this allegation. From record review, it has been observed that R1 fell in the bathroom while S1 was assisting them on 02/14/23. Facility sent out R1 to the hospital to get medical care after the fall incident where R1 was diagnosed with a fractured neck which required surgery to fuse the C1 and C2 vertebrae. During hospital stay, R1 health declined and was placed on hospice care in March 2023. From resident’s interviews, it has been concluded that R1 sustained a fall on 02/14/23 due to staff’s (S1) lack of supervision and care. Facility management received complaints regarding S1’s work ethic, including S1s disappearance during their working shifts. During a department interview with S1 regarding the fall R1 sustained on 02/14/23, S1 did not provide clear answers on what happened at the time of R1’s fall.

During the staff’s interviews, the department interviewed S4 who worked with S1 on 02/14/23. S4 stated that there was a lot of miscommunications that occurred during the shift. S4 stated that they were on their lunch break and heard the radio go off at least eight (8) different times during their 30-minute lunch break to assist R1 back to her room. S4 was called to assist after the fall had occurred with R1 and stated that S4 believed the fall happened due to an improper transfer because of the way R1 was laying on the floor.

During staff interviews, S1 stated that they were frustrated and overwhelmed the night R1 fell (02/14/23). S1 stated that they had been working a double shift. S1 acknowledged that R1 was left in a hallway unattended for at least 40 minutes before S1 arrived to assist. S1 admitted that S1 had never worked with R1 before 02/14/23 and was unfamiliar with R1’s needs. S1 assisted R1 back to their room and R1 in their wheelchair. S1 answered the radio and retrieved some items she had dropped. During this time, S1 observed R1 turn their wheelchair and move towards the restroom for approximately 30 seconds before R1 fell.

Based on review of R1’s facility assessment and needs and service plan which was conducted on 02/01/23, R1 required 1-person total assistance with toileting and transferring. Additionally, R1 was noted as a fall risk and required supervision to reduce the risk of falls.

Based on this information, the allegation’ Resident sustained injury, fracture to spine, as a result of a fall’ is found to be Substantiated.