complaint·April 20, 2023

Report Continued from LIC 9099... It was alleged that licensee neglect resulted in resident sustaining injuries while in care. It was reported that Resident #1 (R1) had an unwitnessed ground level fall while living at the facility resulting in R1 obtaining a potential subdermal hematoma and subarachnoid hemorrhage. Additionally, RP had concerns because R1 had had two (2) within a few days. Review of documents revealed that on R1’s Physician’s Report dated 02/22/2023, indicates R1 is non-ambulatory and is able to independently transfer to and from bed. Correspondingly, R1 was able to walk around with a walker. Interviews with staff revealed R1 tried to get out of bed at night that resulted in R1 having an unwitnessed fall. The staff stated hearing a loud noise which prompted them to check on R1. Staff added that R1 usually called staff when they needed assistance. Interview with resident revealed facility staff often come inside the rooms and check on the residents and stated they have no concerns living at the facility. Additionally, interviews conducted with R1’s family revealed the facility had contacted and reported the falls shortly after they had happened. R1’s family stated that before R1’s first fall, both R1’s family and facility had made a request to attempt and have R1’s Primary Care Physician (PCP) order rails to be placed on the side of R1’s bed; however, R1’s PCP was not responding to the request and was taking too long for the approval. Furthermore, R1’s family stated they do not feel there was any type of neglect from the staff or facility. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “licensee neglect resulted in resident sustaining injuries while in care”. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was issued to the Administrator.