Complaint Investigation Report

According to the allegation R1 had a fall in the facility in early 2022 and staff were unable to pick R1 up. The staff had to allegedly get another resident out of bed to help pick up R1 off the floor. Allegedly staff allowed R1 to wander freely in the facility while staff sat in another room, even when R1 was the only resident in the facility while other residents attended day program off site.

On 11/28/2023, Licensing Program Analyst (LPA) conducted an initial complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation above for record review. LPA received R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) signed and dated 03/01/2022. Under R1’s Mental Condition it is documented that R1 does not have wandering behavior, does not have confused/disoriented behavior, and is able to leave the facility unassisted. Under R1’s Physical Health Status it is noted that R1 has visual impairment, auditory impairment, but does not have motor impairment/paralysis. Under R1’s capacity for self-care it is noted that R1 needs facility staff stand by assistance with transfers to/from the bath. The ambulatory status of R1 states that they can transfer to and from bed but need staff supervision for stand by assistance. The admission agreement to the facility for R1 signed and dated on 02/24/2022 indicates that R1 will receive assistance with personal activities of daily living including mobility tasks. The documented resident appraisal for R1 while in care indicates that R1 has physical disabilities including needing staff assistance to stand and vision loss/degenerative blindness. The resident appraisal of R1 indicates the functional capabilities of R1 as frail or slow, difficulty climbing or descending stairs, requirement of grab bars in bathroom, and that R1 uses a wheelchair. R1 had a facility documented fall in care on 10/09/2022, and on 10/22/2022 a documented hospital referral for R1 Physical Therapy indicated that R1 was referred to evaluate and treat frequent falls as well as unsteady gait from 10/18/2022 through 10/18/2023. The Appraisal/Needs and Services (ANS) Plans for R1 dated 04/01/2022 and 11/10/2022 document under R1’s physical health that they use a wheelchair and/or walker within the facility but have a mandatory wheelchair for the outdoor areas of the facility and on excursions. The persons responsible for implementation are indicated as all staff in the facility.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated.