complaint·March 18, 2023

(continued from LIC 9099-C) Further review also revealed that from the time R1 returned to the facility, R1 was re assessed and put on higher level of care and provided assistance with but not limited to, mobility, dressing, grooming and toileting. R1 was even put on a 1:1 companion for 72 hours upon return based upon the recommendation of the facility staff. R1 had a physician's order to use a hospital bed dated 05/07/20. Further review also revealed that on the Halo rail was checked by maintenance on 08/10/20. LPA's interview with staff on 03/04/23 between 10:00 AM to 12:00 PM, revealed that from the time R1 was adjusting to current medical status (amputation) and confused most of the time so R1 kept on sitting on the edge of the bed like R1 used to prior to amputation, which made R1 slide from the bed and fall on the floor bottoms first. Further interview with staff revealed that due to this behavior of R1, a fall mat was placed beside R1's bed and eventually the Halo rail so R1 had something to hold on and avoid falling on the floor. Based on the information gathered during this and prior visit, the facility put all the necessary protocol to prevent or alleviate the chance of R1 from falling, the allegation therefore is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.