Complaint Investigation Report

The licensee did not ensure care and supervision was to provided to meet the needs of a resident that resulted in a right humerus fracture:

On 10/31/2024, LPA interviewed Administrator (ADM). ADM stated on 10/26/2024, around 12:00PM - 12:30PM, he/she received a phone call from staff S1 saying he/she found resident R1's right arm was not moving and R1 only used left hand to eat lunch, that was different from R1's usual behavior.

ADM stated he/she came to the facility immediately to assess R1, he/she and staff S3 sent R1 to Urgent Care around 2:30PM. R1 had fracture on his/her upper right arm per X ray result. Per Urgent Care doctor instruction, R1 was sent to hospital emergency room around 6:30PM. R1 was discharged from hospital around 9:00AM on 10/27/2024.

ADM stated he/she conducted an internal investigation on 7 staff(S1, S2, S3, S5, S6, S7, S8), but does not know what happened to R1. ADM provided a copy of the 7 staff written statements.

ADM stated R1 does not have seizure and no one saw R1 fell. ADM stated the facility night staff (S6, S7) helped R1 went to restroom around 4:00AM on 10/26/2024. ADM stated S6 and S7 did not report any incident to the morning staff S1 and S2.

On 10/31/2024, LPA interviewed staff S1 on the phone. S1 stated on 10/26/2024, he/she started his/her duty at the facility at 8:00AM. S1 stated R1 was sleeping when he/she started his/her duty. S1 stated the night shift staff S6 and S7 did not report any incident of R1 to him/her. S1 stated R1 woke up around noon time on 10/26/2024. S1 stated he/she was assisting R1 for toileting and shower. S1 stated he/she found R1 was unable to move his/her right arm and called staff S2 to check R1. S1 stated he/she and S2 confirmed R1's right arm was painful and was unable to move and he/she reported to Administrator before 12:30PM.

LPA interviewed 3 residents. 3 Out of 3 residents are nonverbal.

LPA interviewed staff S3. S3 stated he/she and ADM sent R1 to urgent care and hospital. S3 stated he/she did not see R1 fell. S3 stated he/she did not see or hear any one hit R1. S3 stated he/she does not know what happened to R1.