Complaint Investigation Report

Care and supervision: staff did not seek medical attention for the resident in a timely manner.

On 3-14-24 the client fell when returning home from day program around 1400 hours. POA reported being contacted by staff about 1500 hours. POA believes that five to twenty minutes is too long for notification when a client has a fall. Per the general event reports staff provided client with ice and helped elevate knee. Staff reported after about 30 minutes clients was still complaining of pain. Administrator (Admin.) reported arriving at the house approximately 1515 hours and called 911 within 30 minutes. Admin. and staff attempted to transfer client into the van but realized client was unable to assist. Staff reported not calling 911 right away as the client tried to stand twice. The hospital medical records indicated on 3-14-24 at approximately 1646 hours, dispatch received a phone call regarding a sick person. At approximately, 1659 hours, emergency medical services (EMS) arrived at the home. Records report the chief complaint was noted to be knee pain with a duration of time noted as two hours. Licensee reported the ambulance was contacted within 15 to 20 minutes after the clients fall.

LIC 9099 Unsubstantiated: Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, the findings are Unsubstantiated.

Interviews were performed and records reviewed. During record review, number five on the admission agreement states the licensee/administrator or Far Northern Regional Center may terminate this agreement with at least thirty (30) calendar days advance notice to the resident and FNRC. Further review of the admission agreement, number eleven reports the client as ambulatory. It was reported on 3-14-24 the client fell leaving them non-ambulatory. The doctors report indicated the client had knee surgery on 3-26-24 leaving them non ambulatory for 6 to 7 weeks. On 3-27-24, facility staff received a call from POA advising staff that the client requires more care than realized and they would be bringing the client back to the facility. Staff completed a needs and services plan modification and forwarded a copy to LPA. It was determined by staff that they would not be able to provide adequate care due to the non-ambulatory status. A 30-day notice was served on 4-3-24 to the POA and a copy was forwarded to the licensing Program Analyst.