Complaint Investigation Report

Facility Notes indicate R1 suffered unwitnessed falls in her bedroom on the following dates:

- On 09/01/2024 at approximately 1958 hours, R1 was found on the floor lying on her right side on the fall mat. She complained of pain to her shoulder and right side of hip. No other injuries were visible. She was assisted to her bed and provided with pain medication.

- On 06/03/2024 at approximately 2245 hours, R1’s bed motion sensor went off and R1 was found on the floor curled up on her left side. She had a large skin tear and complained of pain. R1 was transported to the hospital to be medically assessed.

- On 05/10/2024 at approximately 2200 hours, R1 was found lying next to her bed. An assessment was completed, and no new injuries were located. R1 was assisted back to her bed.

- On 05/04/2024 at approximately 0920 hours, R1’s bed motion sensor went off. Staff responded and found R1 on the floor. R1 stated she was trying to walk to the restroom and fell. She complained of pain to her back and left hip. R1 was transported to the hospital to get medically assessed.

- On 05/03/2024 at approximately 1500 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on her buttocks on the right side of her bed. R1 was assessed and no new visible injuries were noted. R1 did not complain of any pain. She was placed in her wheelchair and taken out into the hallway.

- On 03/22/2024 at approximately 0115 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on the floor next to her bed. She was assessed and her left wrist was swollen and discolored. R1’s left arm had some deformities. She could not remember how she fell. R1 was transported to the hospital to be medically assessed.

- On 03/22/2024, at approximately 1530 hours, R1’s bed motion sensor went off. R1 was found sitting on the bathroom floor. No injuries were noted. R1 was assisted onto her wheelchair and brought to the main lobby.

- On 02/26/2024 at approximately 1500 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on her buttocks next to her bed. She was confused and disorientated. Staff attempted to place R1 back in her bed. However, R1 refused to. R1 attempted to stand up frequently despite the staff’s redirections. R1 was brought to the common areas for closer staff supervision.