complaint·August 26, 2022

(continued from LIC 9099) Investigator Brian Slatic also attempted to interview Resident #1 (R1)’s family member multiple times from 03/11/21 to 05/03/21, left multiple messages and sent regular mail. Investigator Slatic calls were never returned, and mail was returned too. Regarding the allegation that the Resident sustained multiple fractures while in care, it was alleged that Resident #1 fell resulting to a fractured hip. Investigator Slatic’s record review on 05/25/21 and LPA’s record review on 06/21/21 at 9:00 AM from prior placement at two Skilled Nursing Facility (SNF) revealed that there was no indication that R1 was a fall risk. Physician’s assessment prior to admission did not indicate that R1 was a fall risk. Investigator Slatic’s interview with R1’s Primary Care Physician (PCP) on 05/21/21 at 12:40 PM, revealed that the PCP had been monitoring R1’s progress since admission on 06/10/20. The PCP had a tele medicine visit on 06/10/2020 and 08/28/2020 at which time, the physician stated that R1 is appropriate for the facility up to the time of R1’s fall. LPA’s hospital medical record review also revealed that on 09/30/21 R1 was diagnosed with “acute fracture or malalignment of cervical spine”. LPA’s interview with care staff on 12/22/21, between 10:00 AM to 12:00 PM, revealed that care staff found R1 on the floor at around 7:15 AM on 09/30/21 and medication technician did the pain assessment and called the ambulance immediately, R1 was transported to the hospital at around 7:30 AM on the same day. While R1 sustained fracture during a fall in the facility, the facility staff acted accordingly to have R1 assessed and brought to the hospital immediately. Regarding the allegation the facility staff did not have resident reappraised, it was alleged that the facility did not have a Pre-Admission Appraisal for R1’s readmission on 8/24/20. Investigator Slatic and LPA Tan’s record review revealed that R1 had a Pre-Placement Appraisal Information, Functional Capability Assessment and Resident Appraisal, all signed by a family member on 06/09/20. R1 also has an Appraisal Needs and Services (ANS) prepared on 06/10/20 for R1 but R1’s family member refused to sign and another ANS was prepared on 08/28/2020 upon R1’s return from Covid 19 quarantine from a SNF, which R1’s family member also refused to sign. (continued on LIC 9099-C) (continued from LIC 9099-C) Regarding the allegation that resident sustained multiple falls while in care, it was alleged that R1 had multiple falls while in the facility. Investigator Slatic and LPA’s record review revealed that during the stay of R1 from admission on 06/09/20 and hospitalization on 09/30/20, R1 only fell once. Resident had an unwitnessed fall. R1 was found sitting on the floor of own room by the staff to get R1 ready for breakfast at 7:10 AM on 09/30/20. Further record review also revealed that the facility had an established fall prevention and post fall protocol which was utilized on R1’s fall. R1 did not return to facility after this fall. Based on information gathered during the course of the investigation, the allegations are deemed unsubstantiated at this time Exit interview conducted and report issued.