Complaint Investigation Report

transported to the hospital for weakness, a CT scan showed a blood clot in R1’s brain, physician note states R1 fell a week prior and the blood clot was a result of the fall. It was alleged there was no call button accessible for R1 and staff did not provide a plan in place to prevent R1’s multiple falls.

LPA reviewed R1’s facility record, a Physician’s Report LIC602A dated November 15, 2024 states R1 is diagnosed with multiple diagnoses including Parkinson’s, Wernicke’s, and orthostatic hypotension; R1 has unsteady gate at times, is confused/disoriented, has wandering behavior, able to follow instructions at times and communicates needs most of the time. R1’s needs and services plan/care plan dated December 14, 2024 is marked “yes” next to falls and notes dizziness when standing; however, it does not discuss any plan or mitigation measures for R1’s falls or unsteady gait. Staff interviews, including with the licensee, revealed the facility does not have a fall mitigation plan, but staff were making efforts to monitor R1 by using a motion sensor alarm next to R1’s bed and more frequent checks. Interviews revealed R1 refused to use a walker or cane due to not knowing how to use it. The facility capacity does not require call buttons, and the licensee stated they did not provide one to R1 due to their mental status.

Regarding the incident around Easter 2025, review of R1’s hospital and facility records did not reveal a fall incident occurring on or around April 20, 2025. Staff interviews revealed they are not aware of an occasion around Easter 2025 when R1 fell in their room and the floor alarm was not working.

LPA review of hospital records revealed R1 visited the hospital due to a fall on the following dates: March 19, 2025 resulting in a skin tear to the right elbow; on July 6, 2025 resulting in a laceration of the nose closed with stitches, laceration to the forehead closed with stitches and a skin tear to the left elbow; on August 15, 2025 resulting in a scalp laceration closed with staples. Community Care Licensing (CCL) received incident reports from the facility regarding the falls on March 19, 2025 and July 6, 2025. An incident report for the August 15, 2025 fall was submitted to the department on October 14, 2025.