complaint·May 25, 2021

Regarding the allegation: Resident sustained a fracture and multiple injuries while in care. The Investigation revealed: Residents #1 family member reported Resident #1 had fallen while residing at another licensed facility prior to being admitted to the facility on 03/01/21. At the time of the fall at the other licensed facility, Resident #1's family member made the decision to not to send Resident #1 to the hospital for evaluation. On 03/01/2020, Resident #1's family member moved Resident #1 into the facility. Interviews with Resident #1's family member, Facility Administrator, Facility Staff and review of facility documents; MD visit communication sheets and progress notes all revealed that on date of admission to the facility (03/01/21), staff observed Resident #1 to have resolving bruises to Rt. forehead, neck, and head. On 03/06/2020, Facility caregivers reported Resident #1 fell out of bed and staff called 911. Resident #1 was transported to a local hospital and diagnosed with multiple new rib fractures, multiple contusions in different healing stages, abrasions of multiple sites, etc. Interviews with hospital staff regarding resident #1 medical condition, revealed that the rib fractures were older than expected and were a few days to a few weeks old. It was also noted by Hospital staff that Resident #1 was diagnosed with Osteoporosis, meaning Resident #1's bones were week and Resident #1 could easily break a bone due to this medical condition and Resident #1 was taking aspirin as a blood thinner, therefore, Resident #1 had greater susceptibility to bruising. In conclusion, it remains unknown if Resident #1 injuries/contusions occurred at the Resident #1 prior facility or her current facility. Based on the department's record review and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Zenaida Uy and a hard copy was provided.