Complaint Investigation Report

Resident has sustained multiple falls while in care due to neglect:

On 05/14/2021, LPA interviewed resident R1. R1 stated he/she was fine to stay in the facility. R1 stated he/she was able to get help from staff to get around in the facility whenever he/she asked for help. On the same day, LPA interviewed 3 residents (R2 - R4). 3 Out of 3 stated they got help from staff when they moved from bed, went to restroom or get around in the facility. R3 stated the facility staff reminded residents to ask for help to get around in the facility.

On 5/14/2021, LPA interviewed staff S1. S1 stated 6 residents were assigned as a group and each group was supervised by 1 caregiver; caregivers still help residents in different groups if needed. S1 stated the facility always reminded residents to ask for help whenever they wanted to move. S1 stated R1's hospice care nurse suggested to provide a device for R1 to prevent falls which the facility did not have. The facility communicated with the family member of R1, but R1's family member disagreed to purchase. S1 stated R1 needed help to move around, but sometimes R1 tried to move around by self. S1 denied staff neglected residents.

On the same day, LPA interviewed 4 staff, all of them stated they reminded residents to ask for help when residents wanted to move. All of them stated they always helped residents when residents wanted to move. All of them stated they never neglected residents needed help. 2 staff stated the number of caregivers were enough to provide care and supervision to residents. 2 staff stated R1 sometimes wanted to walk without staff help that caused R1 sustained falls.

On 5/14/2021, LPA toured the facility. LPA observed staff in memory care unit were readily to help residents. LPA observed staff helped residents to stand up from chairs, and assisted residents to walk around with walkers. LPA observed staff helped residents participated in the activities.