Complaint Investigation Report

Progress Notes from 04/01/2019 state that facility staff observed resident R1 with swelling on left hand. Facility staff faxed R1’s physician and notified R1’s Responsible Party (RP). Facility staff requested a mobile x-ray to rule out fracture. The Progress Notes from 04/02/2019 states the Wellness Nurse on duty reported to RP that R1’s x-ray result indicate that R1 had a fracture on left wrist. R1’s primary care physician ordered a stronger dose of pain reliever and provided a referral to Orthopedics, and stated that if R1’s pain persists, then staff should take R1 to ER.

The Incident Report filed by the facility on 04/04/2019 states that on 04/03/2019, facility staff observed R1 with left hand swelling. The Incident Report states that an x-ray was done for R1 and indicated R1 had a fracture. The Incident Report does not indicate which staff observed the swelling on R1’s hand, where R1 was located when staff first observed the swelling, or how R1’s left hand become swollen.

In a letter from RP to the administrator of the facility dated 07/25/2019, the RP states that on April 2019, facility staff S1 notified RP that the A.M. shift found R1 with R1’s mattress askew and R1’s wrist swollen. RP further states that R1 had had nighttime issues including walking at night and an earlier fall.

On 04/14/2019, R1’s Appraisal/Needs and Services Plan was updates to include that R1’s bedroom would have a motion sensor installed that will notify when R1 is walking, and staff will check on R1 when notified. The prior entry on R1’s Appraisal/Needs and Services Plan, dated 04/16/2018, states that R1 has trouble sleeping, and staff are to report if R1 is awake or wandering at night, and R1 has a PRN to assist R1 in sleeping if R1 is up and wandering at night. The Appraisal/Needs and Service Plan was last completed on 04/28/2019 and included as a Special Instruction that R1 will have a private companion everyday from 4:00PM-12:00 midnight.