Complaint Investigation Report

by staff. Due to not being contacted by responsible party, S1 decided to monitor condition of C1 through the PM and overnight (NOC) shifts to monitor for C1’s “if condition worsens”. C1 was unable to walk on their own at 4:16pm on 12/28/2021 and remained unable to walk for over 14 + hours. At approximately 6:51am on 12/29/2021, facility chose to seek medical attention for C1’s foot injury after contacting P1. Facility could have sought medical attention for C1 when the condition was first reported by C1 when C1 complained of injury and was observed by staff, as incident report states, not to be able to walk or bear their own weight on foot. As a result, C1’s condition worsened and C1 had to be taken to the hospital by ambulance on 12/29/2021 at approximately 6:51am. Based on documentation, and interviews staff did not seek medical attention for C1 in a timely manner and the allegation of, “Facility did not seek resident timely medical attention.” Is substantiated at this time.

As to the allegation of, “Facility staff left resident unattended in the hospital emergency room.” It was discovered through documentation and interviews that the facility incident report dated 12/30/2021, states around 8:30am on 12/29/2021, administrator noticed LPT in the facility and asked why they were not at the hospital with C1. LPT stated they “were not needed” (at the hospital with C1). Administrator sent another staff to the hospital to assist C1, who arrived at the hospital at approximately 10:30am. Based on interviews, physicians report and documents, C1 would be unable to safely remain in the hospital independently and communicate effectively with hospital staff. C1 was unsupervised in the hospital for at least 2 hours. Based on the information obtained, the allegation of, “Facility staff left resident unattended in the hospital; emergency room.” is substantiated at this time.

Exit interview, citations issued, report signed, appeal rights and report emailed.