Complaint Investigation Report

Resident fell sustaining injuries due to staff neglect.

On the allegation that the resident sustained a fall due to staff neglect, it is the concern of the Reporting Party (RP) that R1 has fallen a few times since R1 moved into the facility on 05/06/2023. RP stated that on 5/22/2023, R1 was taken to the ER due to a fall and brought back to the facility, only to fall again the next day. To investigate the allegation LPA Urena conducted interviews and record review. Record review of the Unusual /Injury/Incident Reports (LIC 624) submitted to the Regional Office (RO) indicated that R1 had an unwitnessed fall on 05/29/2023 at approximately 6:40 p.m. Staff found R1 on the floor trying to fix their shoe and noticed that R1 sustained two small skin tears to the top of their hand. Furthermore, on the second page of the LIC 624 indicates that Home Health was notified to provide wound care. Staff interviews revealed that they found R1 on the floor and after doing an assessment they noticed a skin tear to the top of the right hand. The staff contacted the licensee and the licensee contacted R1’s physician and home health were contacted to provide wound care to R1’s hand.Staff stated that during the day R1 was closely monitored to assist and tried to prevent falls. Record review of the Home Health “Visitor Care Notes”, revealed that Home Health was providing wound care for R1. On 07/24/2023, LPA Urena interviewed the Licensee. Per the licensee, R1 would get up at night and try to ambulate to the bathroom on their own, and this is the time when R1 sustained the falls. Night supervision is one (1) staff to six (6) residents. Motion detectors devices are placed in each room to detect residents getting up from there bed, consequently alerting the night staff. The LPA observed the motion detector monitor located in the living room and a voice is heard saying the name of the room where the movement was detected. Staff attended to the alert coming from the residents’ bedrooms.

Although R1 fell and sustained a laceration to the top of the right hand due to a fall, the staff provided first aid and notified the licensee. The licensee in turn contacted the physician’s and order home health. Based on the information obtained through interviews and record review, there is insufficient evidence to find that staff were neglectful. Therefore, the allegation is deemed Unsubstantiated at this time.