Complaint Investigation Report

Based on a review of the forms and documents related to R1, it was learned that R1 did not require one on one assistance and was documented as being independent. It was learned that R1 was able to ambulate normally and that there weren't any concerns with R1's ability to ambulate at that time.

Based on further interviews, it was learned that on 06/09/2024, R1 fell during the night shift at about 2116 hours. It was learned that former staff person, S1, was present and witnessed R1 fall.

It was learned that S1 admitted to being in the hallway to observe R1 and saw R1 fall. It was learned that R1 did not require any staff persons to be present in the restroom with R1, nor did facility staff assist R1 more than normal during this time frame.

It was learned that R1 did not have any prior falls that caused any injuries, but that R1 had displayed behaviors of being noncompliant and would slide to the floor. It was learned that facility staff persons would observe this behavior from R1 and report them immediately.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.