Complaint Investigation Report

Allegation “Resident sustained injury while in care:”

It was alleged that due to lack of care and supervision, Resident #1 (R1) fell and sustained an injury while in care. Record review revealed that R1 was admitted to the facility on 07/18/2022. R1’s physician’s report upon admit indicated R1 was ambulatory and had a diagnosis of vascular dementia; care plan assessment indicated that R1 “wanders only within the common areas of the secured community.” Incident report reviewed revealed that R1 sustained a fall on 07/31/2022, resulting in a hip fracture. According to incident report, staff and family member interview, R1 was sitting in a chair in the Memory Care outdoor area. R1 scooted their chair out and into a recessed garden bed, resulting in R1 losing their balance and falling as they attempted to stand up. At the time of the fall, R1 did not require 1:1 supervision, nor did R1 require an escort when ambulating about the secure memory care unit. Incident report and staff interview revealed that staff were nearby when the fall occurred, and that staff followed the proper protocol for obtaining additional medical care and reporting the incident. Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; the allegation that “resident sustained injury while in care” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff do not respond to call button timely:”

It was alleged that on occasion, R1’s family member stayed at the facility with R1 overnight and that R1’s call button was not responded to timely. LPA reviewed Care Point Server records for R1. Record review revealed response times recorded within the identified appropriate time frame reported by facility staff. Interview revealed that there are few residents in the Memory Care unit utilizing the pendant call system. When a resident presses the pendant, the alerts go to the front desk console as well as the staff pagers. Staff then will respond to the resident’s room for assistance. Interview revealed that there are times when staff are busy with other residents, but that the staff work together and communicate with one another to ensure all calls and residents’ needs are met timely. During facility visits throughout the complaint inspection, LPA observed staff tending to residents’ needs and no additional residents identified any concerns related to timeliness. Based on interview, observation, and record review revealed that at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not respond to call button timely” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff do not seek medical attention timely:”

The complaint alleges that a witness observed another resident (Resident #2 – R2) who resides in Memory

Care sitting outside on the patio and according to the complaint, R2 appeared overheated and in need of Report Continued on LIC 9099-C