Complaint Investigation Report

Staff 2 (S2) informed that R1's wrist was swollen, bruised, and R1 stated, "Ouch", pointing to their wrist multiple times, but did not appear to be in extreme pain. Staff 3 (S3) stated that R1's wrist was swollen, not bruised, and R1 moaned slightly upon their wrist being moved, but did not seem to be in extreme pain. Staff informed that R1 was diagnosed with a wrist fracture at the hospital later that day.

Outside source interviews were conducted with R1's Responsible Person and Emergency Contact regarding the incident (OS1 and OS2). The outside sources informed that they were notified of R1's wrist injury and were subsequently present the morning of incident and took photos of R1's swollen/bruised wrist. OS1 and OS2 informed that the facility contacted R1's hospice agency for assessment, but due to the Labor Day holiday the hospice agency was unable to provide an on-site x-ray until 09/02/2025, which would have been two days after R1's injury. Facility staff then requested an x-ray order from R1's hospice doctor so the facility-contracted x-ray company could conduct an on-site x-ray, which would have taken an additional 3-4 hours. The outside sources inquired if it would be faster for R1 to be seen in the emergency room rather than wait for the mobile x-ray, to which staff affirmed. OS1 and OS2 then transported R1 to the hospital themselves. The outside sources informed that upon initial notification of R1’s injury, staff informed that R1's injury was not severe, and the facility did not offer to send R1 to the hospital the day of incident. The outside sources informed that R1 suffered a delay in medical care due to the attempts to secure an on-site x-ray instead of sending R1 to the hospital directly.

Review of facility records evidenced R1's wrist to be swollen, bruised, and showing evidence of pain. Facility Care Notes the day of incident stated, "Resident woke up with a swollen L hand. Seems to be painful to touch. Slight bruising noted." The Unusual Incident/Injury Report submitted by the facility regarding the incident stated, "On 08/31/2025 at 6:00 AM resident seen and examined during grooming and dressing rounds by caregiver. Resident was up walking in [their] room. Caregiver noticed [their] L hand/wrist was very swollen. Called nurse to assess. Some pain to touch." The Unusual Incident/Injury Report further stated that R1 did not recall what happened and the cause of injury was not apparent, R1’s bed was in the low position, R1's Responsible Party (RP) was made aware, R1 was given pain medication, and the hospice nurse assessed R1's wrist. The report further informed that RP drove R1 to the hospital rather than wait for mobile x-ray and assessment by on-call hospice doctor. Photos taken day of injury of R1's wrist showed swelling and purple discoloration to the inner side of R1's wrist and thumb. The facility sent a fax marked as urgent to R1's hospice agency with communication that informed of R1's swollen left hand stating, "Seems to be painful to touch" and that a photo of R1's wrist was sent. (Continued on LIC9099 p.3)