Complaint Investigation Report

On 06/25/2020 LPA Jackie Jin toured the facility via FaceTime. Residents were observed clean and engaged in activities of their choice.

Allegation: Lack of supervision resulting in resident sustaining multiple falls

Between 06/25/2020-07/13/2020 a total of two staff members were interviewed. 2 out of 2 staff stated R1 falls at night between 3am-5am. R1 was using the bathroom and does not want staff to be in the bathroom with R1. Staff get up during the night to check on the residents. All staff stated the residents do not need constant supervision. S1 stated that to prevent residents from falling, the bathroom has grab bars and nonskid mats, and the residents has half bed rails and the beds are lowered.

Between 06/25/2020-08/05/2020 a total of six residents were interviewed. 5 out of 6 residents stated when a resident has fallen, staff will assist the resident back up and check for injuries. One resident does not recall falling at the facility.

Incident report reviewed and noted R1 had two falls, one fall on 06/09/2020 at 3:15am and another fall on 06/13/2020 at 1:05am while going to the bathroom. The facility administrator and staff observed the incident. R1 was accessed for injuries and no injuries were noted. R1’s hospice agency was notified. After this incident, the facility plan was to have more supervision for R1 during the day and requested a different walking aid.

Hospice plan of care indicated R1 is a high risk for falls. The facility staff will assist R1 to the bathroom during awake hours and bedtime. The facility will keep the path clear, label the bathroom, and leave the door open.

Allegation: Facility is not communicating with resident hospice

Hospice notes indicated that on 06/05/2020 and 06/11/2020 the hospice nurse and social worker attempted to contact the facility owner and it went straight to voicemail. Several call attempts were made, and the facility owner did not return call. Hospice notes also indicated that on 06/11/2020 the social worker called the facility owner through an unblocked number, and the social worker was able to speak to the facility owner.

On 06/25/2020 S1 was interviewed and stated the facility landline goes directly to S1’s cellphone when someone calls. S1’s cellphone is available 24/7 and S1 can be reached after 7pm. S1’s cellphone initially was set up to Block an unknown a caller ID. S1 stated to prevent communication issues S1 changed the cellphone set up to receive calls from the hospice agency.