Complaint Investigation Report

When asked how the resident sustained the multiple rib fractures, the staff was unable to provide an answer. It was mentioned that the facility does not have night supervision to know if the resident may have had a fall or unusual incident during the night.

On 12/11/2024, the Administrator was interviewed. Based on interview with the ADM, on 12/02/2024 ADM observed R1 had cough and cold symptoms at day program which prompted ADM to take R1 to urgent care. At urgent care, it was found that R1 had multiple rib fractures. The reason for how R1 sustained multiple rib fracture is unknown. It was stated that the facility does not have an awake night staff to know if the resident may have had a fall or unusual incident during the night. 3 staff members were interviewed. During staff interviews, it was stated that R1 started to show symptoms starting on 11/29/2024 of a light cough, difficulty standing for a long period of time, shortness of breath, slouching, and difficulty hunching over to put his/her socks on. Staff believed R1 only had a cold and was providing R1 water from Friday – Sunday. On Monday, 12/1/2024, staff observed that R1’s condition was not improving and was brought to urgent care where it was found that R1 sustained multiple rib fractures. Staff was unsure how R1 sustained the multiple rib fractures as they do not have an awake night staff to observe if R1 had a fall or unusual incident the night before.

Based on record review of R1's IPP, it states that "R1 has an additional NOC staff on the schedule due to nighttime wakefulness and to ensure his/her health and safety". The review of the facility’s direct care staff schedule shows that the facility schedules an awake night staff from 11PM – 6AM, however, based on interview with the Administrator, the facility actually does not have an awake night staff. 3 out of 3 staff also confirmed that the facility does not have an awake night staff.

The Department has investigated the above allegation. Based on interview, record review and observations the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. See LIC9099-D. A case management – deficiencies visit was conducted due to violations observed during the investigation. This report was reviewed with Administrator, Remedios “Remy” Bose and a copy of the report and appeal rights was provided. Page 2 of 2.