complaint·July 6, 2022

The complaint was referred to the CCL IB investigation Unit and assigned to IB Investigator Brian Slatic for full investigation. IB investigator Brian conducted and completed the investigation which included interviews with the family members, responsible party, facility administrator, five facility staff and Resident#1 (R1)’s former roommate. IB Investigator Brian also obtained Hospital Record, hospice documents and shower records. The investigation revealed the following: Allegation “Resident sustained an unexplained fracture while in care.” The investigation revealed that R1 was non-ambulatory and required the use of a wheelchair and required at least two staff members to transfer from the bed to the wheelchair. R1 sustained a fracture to the right femur and the facility reported that they were not aware of any falls or any other explanation for how R1 sustained the fracture. All direct caregivers denied any knowledge of a fall or any other event that could have caused R1’s fracture. Resident’s facility and hospital records were also reviewed during the investigation. Per review of hospital records, the emergency room doctor stated that the fracture was most consistent with a traumatic injury such as a fall and yet there was no evidence of a fall. Per review of the facility records, the resident did not have a history of falls. The resident’s facility doctor does document that the resident has severe osteoporosis, which would make the resident very susceptible to a fracture without a traumatic event. Therefore, there’s no sufficient evidence to support the allegation of resident sustained an unexplained fracture while in care. Therefore, LPA finds the allegation to be UNSUBSTANTIATED Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur., therefore the allegation is UNSUBSTANTIATED. An Exit Interview Conducted and a copy of the report and appeal right was provided to Administrator Pamela Ogot.