Complaint Investigation Report

On the allegation: Staff did not prevent a resident from sustaining multiple falls.

It was alleged that R1 had a fall on 06/27/25 in which R1 hurt their knee, alleged that within twelve hours of the first fall the resident got up to use the bathroom and fell and hit [their] head and was transported to the hospital. Reporting party stated that R1 lost 2 pints of blood. Records indicate there were 3 incidents, all unwitnessed, all occurred in residents’ room within a 24-hour timeframe, 2 on 6/27/25 and 1 on 6/28/25.

On 6/27/25 R1 was found at approximately 7:00 am by medication aid during medication pass, R1 was on the floor in their room. Records state and staff interviews confirmed staff assessed R1 for injuries, initially R1 verbalized no pain or injury, staff got R1 off the floor and immediately observed R1 limping and facility contacted 911, per interview with Wellness Director (WD) first responders assessed R1 and spoke with R1 and R1’s family member (F1). Medical transport was refused after the conversation, and additional medical treatment was not sought by the request of R1 and F1. Records show that at 9:55 am R1 was given a prescription PRN Tramadol for pain. Facility records show NP was notified of incident at 1:06 pm via fax. Facility submitted an incident report to Community Care Licensing (CCL).

On 6/27/25 at approximately 1:45 pm staff heard R1 yelling for help, R1 told staff and records state that R1 was trying to open their door and fell. Physical Therapy referral requested. WD stated the fall was due to R1 not having shoes on. R1 was assessed, no injuries present. Facility records show NP was notified of the incident at 11:25 pm via fax.

On 6/28/25 R1 was found during the medication pass at approximately 5:30 am. Interviews and records state medication aid walked in and observed R1 on the floor and noted a “head injury and resident near [their] bed on the floor.” Facility called 911 and stayed by R1. Records state, “resident unable to give description” of what had happened and that “Resident appeared disoriented.” The incident resulted in unknown head injury, with blood loss. Review of R1 medication records shows they were on a blood thinner.

During record review, LPA noted that physician’s order dated 6/2/25 and 6/16/25 for PRN Tramadol stated, “1 tablet orally at bedtime as needed for pain”. During an interview LPA was told that medication was given the morning after the incident and Medication Administration Record (MAR) showed R1 took a PRN tramadol at 9:55 am on 6/27/25. Interview at 3:20 pm on 7/25/25 with NP, LPA inquired why PRN was ordered for “bedtime”. NP stated prescribed “at night, in case the resident gets tired from the medication, and so they don't fall." Continue on 9099-C