Complaint Investigation Report

Staff 1 (S1) interviewed indicated he/she changed R1's briefs and while S1 was cleaning, R1 used his/her walker to leave the room and walked to the bathroom. After S1 was done cleaning, he/she did not observe R1 in the hallway so immediately checked the room next door and the bathroom across the hall and found R1 in the bathroom between the wall and commode slipping. S1 indicated he/she did observe R1 slip. Resident Care Coordinator and the med-tech on shift assessed R1 after the fall and called 911.

Therefore, based on interviews conducted and record reviewed, the department has determined that although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Acting Administrator and a copy is provided.