Complaint Investigation Report

According to R1's LIC 602 Physician's Report dated 04/04/2023, R1 is diagnosed with dementia, max supervision is needed, and it is noted to have wandering behavior in bedroom only. R1 is ambulatory. According to a Resident In-House Assessment dated 02/26/2024, R1 is on status checks 4 times per shift and ambulates independently with or without device, needs assistance with ADLs, and is not on a special care plan. The Resident In-House Assessment was updated on 05/21/2024 with minor changes. Status checks remained at 4 times per shift and ambulation requires 1 person total assist or wheelchair escort.

Facility documentation and documentation provided by the RP show that R1 sustained falls on March 11th, March 24th, and April 9th. During those days, the staff scheduled showed a total of four (4) staff members on AM and PM shift to work in the memory care living area.

According to facility documentation, an incident report dated 03/08/2024 showed that staff was on the way to an elevator when staff heard a thud. Staff turned their head and saw R1 on the floor. Staff responded and the medication technician was notified. Hospice and R1's conservator was notified of the incident. First aid was administered and it was noted that the resident did not go to the hospital. Hospice records show that a nurse conducted a follow up visit on 03/11/2024 to care for the injuries for the fall. R1 had cuts on face, Band-Aids were replaced, and R1 appeared at baseline. Another hospice entry was documented for a routine visit on 03/11/2024. The nurse wrote, "Pt fell on Friday, injuries to leg, bandage take off. No bleeding notes. No signed of infection. Checked for cut to face from fall, they are superficial cuts from the fall. Left it open to air."

On 03/24/2024, the hospice nurse was notified of a fall. The nurse documented the following: "Assess skin tears - wound to right side of face after fall this AM. Will send nurse tomorrow to cleanse and dress laceration." On 03/25/2024, the noted stated "Routine visit - checked Pt in hallways, calm/quiet, S/P fall with injuries, no signed of infection."

After 03/24/2024, LPA did not observe any additional notes from Bristol Hospice. According to an interview with the administrator, the hospice agency was not always consistent with notes and R1 was in process of changing hospice companies.