complaint·May 17, 2023

Resident sustained unexplained injuries. During this investigation, staff and residents were interviewed and facility and medical records were reviewed. S2 acknowledged the incident in question and stated that S1 reported an incident on 01/12/2023 which resulting in R1 falling and sustaining a fracture. Specifically, S1 said R1 fell while in the bathroom during a diaper change. Present for the incident was S1. Based on interview with S1, R1 did not present any significant indication of immediate distress after their fall. S1 clarified that the incident was a fall that S1 witnessed versus an unwitnessed fall from R1’s bed. S1 was changing R1’s adult diaper when R1 abruptly tried to "bolt" away. In the process. S1 held onto R1’s adult diaper and pants to prevent R1 from falling or injuring themself. As a result, R1 fell backwards and onto S1. S1 was questioned as to why S1 did not call 911. S1 indicated that R1 did not appear in any distress, nor complained of pain. After the incident, S1 immediately reported the fall to facility management. Interviews indicated that S1 actively checked on R1 throughout the night to assess for a change in condition. S1 indicated that after R1 reported being in pain on 1/13/2023, R1 was promptly taken to the hospital. Based on the information and evidence, it was determined there is insufficient evidence to substantiate the allegation, therefore the allegation is unsubstantiated. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED. Exit interview was conducted with House Manager and a copy of this report was provided to the facility. The signature of the House Manager on these forms acknowledges receipt of these documents.