Complaint·August 24, 2023

On 02/12/2023, at 3:30pm, LPA Reed briefly spoke with facility staff and R1. At 3:40pm, LPA requested facility records. On 03/02/23 between 10:55am and 1:30pm, Investigator Edward spoke with the Executive Director (ED), facility nurse, and other facility staff and reviewed facility records relevant to investigation. Records included but were not limited to R1’s physician report, Needs and Service Plan, facility internal incident log, copies of incident reports involving R1, and other documents. Information received revealed that staff utilize a Hoyer Lift to assist R1. On 02/28/2023, at 4:00am, S1 attended R1 for incontinent care. While changing R1, S1 did not use the Hoyer Lift. R1 slid down the bed and was about to fall. To prevent the fall, S1 grabbed R1 by their right arm “between the shoulder and the elbow" and assisted R1 to the ground. To assist R1 back to bed, S1 called Staff #2 (S2) from the facility next door to help. S1 and S2 used a Hoyer lift and transferred R1 back to bed. No body assessment was performed prior to putting R1 to bed. Interviews revealed that the incident was not documented or reported by S1 or S2 and between 4:00am and 8:30am. R1 was not attended to by S1 or other morning shift staff. On or around 8:30am, R1’s private aid arrived at the facility and observed R1 to be in pain with a swollen right arm. The private aid informed facility staff, and they reported to the facility nurse. The follow up actions were taken by the facility staff on or around 9:30am. Overall information gathered from the documents supported the information revealed from interviews. Based on inspection, observation, interviews, and record review, there is sufficient information to conclude that R1 sustained injuries due to improper assistance. Therefore, the allegation is SUBSTANTIATED at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.