Complaint Investigation Report

The following day C1 was still not able to get up and continued to complain of shoulder pain. S2 called the Administrator, and the Administrator instructed S2 to call 911. At 0949 hours, a call was made requesting emergency medical services. C1 was transported to the hospital and diagnosed with a right broken humerus. Per the hospital notes: “It is important that we prevent future falls for C1, as C1's Xarelto medication makes C1 higher risk to have major bleeding including bleeding inside of C1's brain which could result in permanent brain damage or even death.” Additionally, C1 was left on the floor after the fall for an extended period of time, before calling Administrator to drive to the facility and then help C1 off the floor. At this time there is enough evidence to support the allegations of, " Facility staff did not seek medical attention for resident in a timely manner." and "Staff left resident on floor for an extended period of time." and both are substantiated at this time.

Exit interview, report read, citation issued, appeal rights and report provided.