Complaint Investigation Report

LPA Rosales interviewed staff and Administrator on 04/30/2021 at 10:39 AM, 12:07 PM, and 2:23 PM. LPA Rosales interviewed staff on 06/04/2021 at 2:21 PM and on 06/07/2021 at 4:14 PM. LPA Ascencio interviewed staff on 05/05/2022 at 2:50 PM. LPA De Leon interviewed staff on 04/16/2023 at 11:45 AM and 11:59 AM. LPA Rosales received documentation on 05/18/2021, 5/24/2021, and 08/26/2021. LPA De Leon reviewed documentation from 04/12/2023 – 04/17/2023. LPA De Leon requested additional documentation on 04/17/2023.

On the allegation: Staff did not seek timely medical attention for resident. LPA’s Rosales, Ascensio and De Leon interviewed a total of 18 people during the investigation. LPA Rosales interview with Administrator stated that R1 had an unusual condition. R1 was experiencing pain. Administrator stated that at one-point R1 rolled out of bed and immediately staff sent R1 out for Xray, R1 had verbalized pain in R1’s hip area, x-rays were all fine, the resident then experienced a change in condition. S5 interview revealed R1 had 7 weeks previous to an incident with R1 on 05/19/2021 R1 had fallen and had a fracture on R1’s hip joint which is why R1 needed to stay in bed or in a chair, R1’s doctor said R1 didn’t need surgery. S5 said Staff have been using a lift because R1 cannot weight bare. S5 admits S5 did not call R1’s family to let them know about the change in condition. Staff interviews revealed R1 had a fall on the NOC Shift at some time during the early am of 04/13/2021. Staff Notes were written in the system by S12, and the entry could not be produced by the Administrator. R1 was not sent out after the slip or fall out of bed on 04/13/2021 early am, notes produced by the facility showed entry on R1 by Staff on 04/13/2021 at 1:40 PM very week today, had to use another resident’s wheelchair to transfer, right side of face was swollen and has a bruise on his right elbow. Had to have assistance today for both meals with feeding, in bed laying down. A later entry on R1 by another staff dated 04/13/2021 10:22 PM, R1 had difficulty with standing, needed a two person assist, complained of pain when moving, ate 100% of dinner, wanted to get up and walk, took a few steps with difficulty unable to take a step with left leg, two guides assisted with R1 wanting to walk, no complaints of pain at time.