complaint·September 5, 2025

***CONTINUE FROM 9099*** An internal incident report is completed, and the responsible party is contacted.” S2 stated, “In this situation, we assessed and called hospice, and notification to the person in charge happened right away.” S3 provided the incident report and change of condition log, which reflected that staff documented the fall, assessment, and communication with hospice. S4 also confirmed that she notified the med tech immediately after discovering the situation. LPA’s review of the communication logs and call logs confirmed that notifications were made to hospice and to responsible parties after the incident. Documentation reviewed included the internal incident report with instructions and protocols for care following the fall. Interviews with staff were consistent in describing the procedure: caregivers alert the med tech and unit lead, complete incident documentation, and notify hospice and the responsible party. Allegation: Staff does not meet training requirements - Unsubstantiated LPA reviewed three staff files (S1–S3), including annual training logs, and continuing educa tion records. LPA also reviewed R1's file. R1 is on hospice. W1 reported, “An untrained med tech who is not a nurse assessed whether or not my mother was okay.” Interviews with staff confirmed that the caregiver on duty notified the med tech, who then notified the nurse and hospice. S4 stated, “I notified the med tech right away to escalate it after finding out the situation in Room 119.” ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Staff files reviewed by LPA contained documentation of orientation, and annual continuing education hours were reviewed.Training logs showed that caregivers and med tech had completed the mandated annual training. S3 provided LPA with the internal incident report and care plan for R1, which confirmed that documentation and reporting protocols were followed. Staff interviews with S1–S4 revealed facility’s process for immediate reporting to the med tech, escalation to the nurse, and notification of hospice and responsible parties. This agency has investigated the complaint regarding allegation above. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. .Exit interview conducted, a copy of this report provided.