Complaint Investigation Report

Based on the interview conducted with resident (R1)’s Family Member (FM1) on 10/29/2024, FM1 is aware of R1’s fall history and stated that R1 likes to do things on their own and doesn’t call for help. R1 was getting up and falling without assistance and people around due to medicine drowsiness. R1 had a cut on her backside and a bruise on her cheek. FM1 stated that this particular incident related to bruising was an unwitnessed fall. The facility is not sure how it happened and what caused the bruising. Most probably R1 hit the corner of the bed when they tried to move from the bed to the wheelchair on their own. Probably hit the chair or bed. R1 has Parkinson's dementia. R1 knows they can’t get up on their own. FM1 worked with R1’s doctor to change the medicine so that R1 is not always drowsy. No falls since the change of medicine. FM1 stated they hired a private companion for R1 and adding a private companion helped. FM1 is evaluating if R1 needs a skilled nursing home more than an Assisted Living facility. FM1 stated that the facility is doing a good job taking care of R1, giving medicines, showering, giving meals, and dressing. FM1 have been at the facility when they were working with R1. FM1 has no concerns about the facility, and they got a call every time a fall incident happened, and an EMT was called on all occasions.

Based on the interview conducted with staff (S1) on 10/30/2024, S1 stated that R1 moved into the facility about 2 months ago. R1 moved to Assisted Living from rehab with a dog. The facility evaluated and moved R1 from Assisted Living to memory care on the first day only. R1 was constantly tripping over the dog. The dog was handed over to R1’s FM1. S1 stated that R1 is confused, agitated, and suicidal at times, and has a high fall risk. R1 always tries to get out of bed and wheelchair on their own. R1 was in the hospital with bruising. The facility had a care plan around that. R1 is back in the facility from skilled nursing after the last surgery for a fall. The staff brings R1 to the common area of the memory care to do activities and manage and prevent falls/injuries. R1 is angry. R1 doesn’t want to be here. R1 is in her 90s. Bruising is due to the falls. All of R1’s falls are documented/reported on internal charting notes. Staff keep observing R1’s bruising and document its status. S1 stated that R1 has a personal companion from 12-8 PM. This changed her condition. R1 is more clear now. At nighttime, there is no personal companion. However, the facility’s care staff is there during the night shift. R1 has a pendant. R1 is using it. R1 is refusing medication at times. S1 stated that facility staff contacted and worked with R1’s responsible party, doctor, and skilled nursing home to address the injuries from fall incidents and help in managing the falls.

Based on the interview conducted with R1’s Personal Companion (PC1) on 11/05/2024, PC1 stated that the facility has been doing well in taking care of R1. R1 has been doing better. Caregivers are always attentive to R1. R1 tries to get out of bed knowing they can't walk and that is the reason they fall. R1 has been active, and the bruising is getting better. R1 has no fall incidents in the past 10 days.