Complaint Investigation Report

Staff neglect resulted in a resident sustaining a fracture due to a fall.

On October 20, 2024, R1 sustained a fall at the facility while attempting to stand from a reclining chair and reach for a walker without staff assistance. As a result of the fall, R1 suffered a displaced fracture of the right femoral neck, as confirmed by medical records. Based on R1’s physician's report (LIC602), R1 required assistance with transferring and bed mobility. Additionally, R1’s family had previously informed the facility that R1 required assistance with all transfers and needed supervision when ambulating due to a known fall risk. The department attempted to obtain R1’s assessment and needs and service plan from the facility however the licensee indicated the facility did not have requested documentation. R1 was admitted to skilled nursing for rehabilitation and returned to the facility on 11/15/2024. Based on the investigation, the facility did not implement appropriate supervision or safety interventions despite having prior knowledge of R1’s fall risk in addition to the absence of updated needs and service plan. Based on the information gathered, above allegation is SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Staff neglect resulted in a resident sustaining multiple pressure injuries.

On February 5, 2025, a Home Health nurse notes report a new wound was observed on R1’s coccyx. The wound measured 5 x 4 x 0.3 cm and was documented as a suspected deep tissue injury. Medical records indicate staff were unable to report when the wound had developed. As a result, wound care orders were initiated. The investigation determined that the facility did not consistently implement pressure injury prevention and wound care measures as directed by home health nurse. This failure resulted in R1 developing a Stage 4 pressure injury to the coccyx, as well as a worsening pressure injury to the right heel. Based on the investigation, the department substantiates the finding that staff neglect resulted in R1 sustaining multiple pressure injuries. Based on the information gathered, above allegations are SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.