complaint·April 16, 2025

On 02/07/2025, between the hours of 2PM-4PM, Investigator Hector conducted interviews with R1 and R1’s responsible party. Information gathered during the course of the investigation revealed that R1 attempted to transfer without assistance around 12:40AM on 11/15/2024, resulting in a fall. R1 requires transfer assistance and has a bell next to their bed to call staff for assistance. R1 did not ring the bell or notify staff before attempting to self-transfer. Staff immediately found R1 and called for paramedics who transferred R1 to the hospital for further evaluation. Facility notified R1’s responsible party. R1’s medical assessment dated 06/17/2024 identifies R1 as a fall risk and that R1 and care-staff shall be instructed on fall prevention measures. The facility implemented the bell next to R1’s bed to mitigate fall risk. R1’s appraisal dated 07/22/2024 and physician’s report dated 04/04/2024 document R1 as alert and social without dementia. R1 stated that the fall was not the facility’s fault and took accountability. R1’s responsible party had no concerns of lack or quality of care from staff. Based on the above information gathered, although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Resident fractured their hip due to lack of care from staff” is deemed UNSUBSTANTIATED at this time. LPA reviewed report with Administrator telephonically. Administrator was unable to be present for the visit and designated staff Lina Roxas to sign the report. No citations issued at this time. Exit interview conducted and a copy of the report was provided.