Complaint Investigation Report

When the fall occurred, facility staff were nearby and heard the fall and immediately came to assist R1 by providing first aid. R1 was not able to tell staff the cause of the fall due to having dementia. However, according to staff, R1 was able to get up and did not complaint of any pain. According to interviews with staff and outside parties, R1 did not have a history of falls during the two (2) years they had lived at the facility nor did R1 have a history of falls prior to moving into the facility. Staff indicated that R1 enjoyed walking inside the facility and was able to walk around without a walker or a cane with no problems. Based on the information gathered during the interviews conducted with staff and outside parties and the information obtained from the records reviewed, there was insufficient evidence to indicate that facility staff were neglectful in the supervision of R1 that could have contributed to R1’s fall.

It was also alleged that facility staff did not administer medication according to physician's orders. Interviews conducted with staff and outside parties revealed that R1 was taking medication for high blood pressure. During interviews, staff consistently indicated that all medications including the medication to treat high blood pressure were administered to R1 according to physicians’ orders. All medications including the high blood pressure medication were delivered by the pharmacy every month, and the high blood pressure medication was in the “bubble packs” which made it very easy not to miss any doses. Review of R1’s Medication Administration Records indicated that all medications were administered as prescribed, Specifically, staff indicated that because R1 had a history of high blood pressure, they were diligent about giving the medication to R1 every morning as prescribed.

The Department has investigated the above-mentioned allegations and has found that based upon interviews and record reviews, there is insufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are deemed to be unsubstantiated.

An exit interview was conducted with Administrator, Carina Carmona. A copy of this report, and Licensee Appeal Rights (9058 01/16) were provided to Administrator after the conclusion of the visit.