Complaint Investigation Report

Lack of supervision- Resident suffered broken ribs.

During the investigation, numerous persons were interviewed, and several documents were obtained. Documents included X-rays, Physician Medical Records, lab results, Medication Records, Physician’s Report, Individual Program Plan, Functional Capability Assessment, Facility Notes, and Admission Agreement.

During the interview process, it was reported that a resident (Resident 1) sustained broken ribs. It was unclear when and how the injury occurred, as there were no direct witnesses. It was stated that staff denied seeing any signs of bruising or anything to indicate that the resident was injured. Resident is nonverbal and could not communicate that she suffered an injury; the resident did not have a specific gesture to express pain. It was indicated that it may have been possible that the resident fell out of her wheelchair and suffered broken ribs, which was undetected by staff.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated .