complaint·September 27, 2024

Personal Rights. On the allegation of personal rights violation, the Reporting Party (RP) alleges that the staff were neglectful, consequently Resident #1(R1) sustaining multiple fractures due to a fall. To investigate the allegation the LPA conducted record review pertinent to the investigation. LPA Urena was unable to interview R1 due to R1 is no longer residing at the facility. LPA Urena attempted to interview the reporting party and responsible party; however, was unable to reach them. The LPA interviewed Staff (S1) on 09/12/2024 at approximately 12:49 p.m. S1 stated that on 05/28/2023 at around 7:30 a.m., they found R1 sitting on the floor when they made the morning rounds to assist with breakfast. S1 asked R1 what happened, but R1 did not remember. S1 assisted R1 to stand up, but R1 could not put pressure on the left foot due to pain. Left foot appeared slightly swollen. S1 alerted the med tech and administrator to the fall and R1’s condition. The med tech contacted R1’s physician. The administrator contacted R1’s responsible party. The administrator contacted an ambulance to take R1 to the hospital for further assessment. The LPA interviewed the administrator on 09/12/2024 at approximately 12:35 p.m. The administrator stated that they stayed in touch with the hospital and were informed that R1 would be transferred to a Skilled Nursing Facility (SNF) after being discharged by the hospital. Medical records indicate that R1 was discharged to the SNF on 05/31/2023. R1 did not return to the facility after being discharged by the SNF. The record review of R1’s physician’s report dated 02/12/2023, and R1’s Resident Appraisal/Needs Service Plan assessment dated 02/13/2023 revealed that R1 was ambulatory while residing at the facility which was from 02/13/2023 through 05/28/2023, and R1 did not have a history of falls. Furthermore, the LPA reviewed the medical records pertinent to the allegation of fractures. The medical records indicate on 05/29/2023 that R1 was admitted to the hospital due to pain and slight swelling of the left foot after a fall, and X-rays of the left foot were taken. The X-rays showed nondisplaced fracture of the third metatarsal (toe), and a subtle fracture through the distal fibula. Additionally, medical records indicate that R1 was awake, but disoriented to place time and events at time of admission; however, R1 was able to follow commands, and speech was clear. No other fractures or injuries were noted due to the fall. Although R1 did sustain fractures to the left foot due to the fall; at the time of the fall, R1 was ambulatory and did not have a history of falling. The staff also followed protocol to assist R1 once staff found that R1 had fallen. Staff notified the R1’s responsible party, R1’s physician and got help for R1 in timely manner. Based on the information obtained through record review and interviews; the allegation that staff was neglectful, is deemed Unsubstantiated at this time. Pg. 3 Facility staff did not assist resident with showering as needed. On the allegation that Resident 1 (R1) was not assisted with showers as needed, the Reporting Party (RP) alleges that R1 was only showered once a month. To investigate the allegation, the LPA interviewed the administrator, and Staff #1 (S1). LPA Urena was unable to interview R1 due to R1 is no longer residing at the facility. LPA Urena attempted to interview the reporting party, and responsible party; however, was unable to reach them. The administrator’s interview revealed that although, R1 could shower themselves, the administrator stated that R1 was assisted with showers two times a week. The administrator stated that the responsible party was specific about the days they wanted R1 to receive assistance with their showers. The S1’s interview revealed that in addition to the showers, S1 would assist R1 with shaving, nail clipping, etc. The S1 provided the LPA with a schedule followed by S1 for the services provided to residents in care at the facility. LPA Urena conducted residents’ interviews related to showers, and residents revealed that they could either shower independently or were assisted twice a week by staff if needed. Based on the information obtained through record review and interviews, the allegation that Facility staff did not assist resident with showering as needed, is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of the report was issued.