Complaint Investigation Report

The Department obtained R1's facility records, which indicated they moved into the facility in November of 2023. Their October 2023, Physician’s Report indicated that they were non-ambulatory and required assistance with transfers and bathing, which was to be provided twice per week. Prior to their move-in, they were diagnosed with a cracked vertebra and were considered a high fall risk. They required daily routine checks and escorts with staff, along with using a walker for long distances. According to two staff members (S2 and S3), there were times when R1 did not recall that they needed their assistive device, and would forget to use it when walking. According to a Service Plan dated December 29, 2023, R1 also had a risk of skin breakdown and required daily skin checks in which staff were to look for redness, discoloration, or open areas of the skin. Staff were to provide bathing, which included monitoring for skin issues twice a week. According to the Pre-hospital Patient Record, R1 was also on blood thinner medication.

Facility case notes revealed that on November 11, 2023, R1 sustained a witnessed fall within their first week of care, which resulted in a skin tear. According to facility notes, R1 did not complain of pain, and minor first aid was provided. R1’s Responsible Party (RP) was notified on the same day, which was corroborated by RP when interviewed by the Department on April 12, 2024. 10 days after the fall, on November 21, 2023, the facility noted a change in condition, as R1 began to present with discoloration in their leg. No notation was made indicating that R1’s RP or Physician was informed on the day of the observation, nor was medical care obtained. It was noted that the RP was notified more than 24 hours later, which was corroborated during an interview with RP. On November 22, 2023, an Outside Source (OS1) expressed concern regarding the facilities delay as R1 was on blood thinners, which means “she’ll bleed more”.

On December 2, 2023, staff annotated R1 had a hematoma on the left side of their hip, however it was also noted that RP was not made aware until one day later, December 3, 2023. In February 2023, R1’s case notes indicated that a staff member [S1] observed them with an unexplained skin tear to the right arm and a bruise on the wrist. It was noted that another staff member was notified, but not R1’s Responsible Party, which was corroborated by RP.