Complaint Investigation Report

Resident sustained a fracture while in care due to lack of care/supervision. – UNSUBSTANTIATED

It was alleged that a resident was left unsupervised and sustained a fall with injury as a result.

LPA reviewed an incident report dated 02/03/24 in which it was reported that at 1:00 PM Resident 1 (R1) had a witnessed fall in the dining room resulting in a left hip fracture. Resident stood up from the dining table and was starting to walk with her walker when she lost her balance and fell backwards. Staff was unable to get to R1 in time to assist with her fall. R1 is independent with transfers and mobility with her four wheeled walker. Resident did hit her head on the wall after she fell and did not lose consciousness. Resident was able to get up from the floor with assistance and take small, short steps. Resident's pain had increased shortly after and was then sent to the ER for evaluation. Resident was taken to ER via ambulance. Persons contacted: Monica Gralian PA-PCP, Jack- son, Nicole Braswell LVN- Administrator, Nancy Martinez- Wellness Director.

During staff interviews 3 of 3 staff stated the fall occurred in the dining room and was witnessed by staff. 3 of 3 staff stated R1 lost her balance holding her walker.

Memory care director stated R1 appeared to have gotten up from the table and she fell back. Staff saw it and tried to run to help her but didn’t make it in time.

Administrator stated It was a witnessed fall. R1 was getting up from the table to leave the room and a caregiver was there but was escorting another resident. The caregiver heard R1 call out and she turned around but was not able to get to R1. Staff contacted the administrator when R1 initially fell, she said she was not in pain. Administrator asked staff to call the family and ask what they would like. About an hour went by and the administrator didn’t hear anything. The med tech told the administrator that R1 had increased pain, so they called EMS. The family had called back and said, “No don’t send her out.” The med tech told the family that they were making the decision to send her out.

It was determined that the resident was in the dining room with staff present when they fell, the fall was witnessed by staff. The resident was not left unsupervised. The facility followed their protocol of notification. The allegation is unsubstantiated.