Complaint Investigation Report

The resident was found by Staff members during the first check of the residents in the morning at the facility. According to LPA interview with Licensee, Staff, and residents, the residents are checked every few hours during overnight supervision. The Incident Report from 07/31/2023 and LPA interview with Staff members indicated that the resident had fallen prior to the Staff check in at 6:00am, but after the 4:00am Staff check in. When the injuries from the fall were observed by Staff members at the 6:00am check in, the appropriate actions were taken as evidenced by interview and record review of Emergency Department Patient Discharge Instructions, Physicians Notes/Orders, and the Centrally Stored Medication and Destruction Record.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff did not seek timely medical attention for a resident. It is alleged that the Staff members cleaned the resident who sustained a fall, and the room of the resident before notifying the resident’s family. The allegation states the resident was bruised and bleeding, but Staff did not seek medical treatment for the resident.

Licensing received a timely Incident Report from the facility detailing the events of the fall and injuries to the resident on 07/31/2023. The incident report states that the resident was found in their bed with laceration above the eyebrow, bruising to the right eye, and a small laceration on both arms. The wounds were cleaned by Staff members and pressure was applied to the laceration. The Responsible Party/Power of Attorney for the resident was notified, and the resident was brought to the Emergency Room. In the Emergency Room medical tests were ordered for the resident including a Blood Test, EKG, Chest X-Ray, and a CAT Scan of the Head and Spine. The resident was discharged and returned to the facility with a diagnosis of Closed Head injury requiring the ordering of antibiotics and a follow up visit with the resident’s primary physician within 1 month. On 08/14/2023, LPA received Emergency Department Patient Discharge Instructions for the resident. The antibiotics are listed on the Centrally Stored Medication and Destruction Record kept by the facility for the resident in care. LPA received physician’s notes for the resident that stated to give the resident the antibiotics as ordered and to monitor the resident for worsening symptoms.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.