complaint·April 7, 2025

The investigation revealed the following: Allegation: Resident sustained an unexplained fracture. It is alleged that R1 sustained a fracture due to lack of care and supervision. This allegation was investigated by Investigations Branch (IB) investigator J. Canto which revealed the following: During interviews with facility staff members, they stated R1 sustained a witnessed fall on 01/21/2025, R1 was assessed and stated they were not in pain and the POA was contacted and informed of the incident. About 2.5 hours post fall R1 was noted to have discomfort and showed signs of pain. The facility Med-Tech assessed R1, contacted the POA, updated them on R1’s condition, and recommended R1 be transferred to the local hospital for further evaluation. R1 was transferred via ambulance to hospital. The incident was recorded via the facility's closed-circuit monitoring system, J.Canto reviewed and confirmed the incident. Video showed R1 using their wheelchair as a walker (personal preference), enters bedroom, a few seconds later a caregiver’s side profile is seen entering the bedroom in a fast manner, two other caregivers responded, and one of them called for further assistance. J.Canto asked why R1 as not transferred to the hospital immediately after the fall and S1 stated that the fall was witnessed, R1 did not hit their head and initially said they were without pain, once staff were informed of pain R1 was transferred to the hospital where they were diagnosed with a fracture. Based on statements and interviews conducted with staff/residents, and the information obtained regarding the incident via the staff members being consistent with what was recorded on the video investigator J.Canto found no evidence to corroborate the allegation of neglect and lack of care & supervision by the facility and there was not enough supportive evidence to concur with the reported allegation. 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 . Exit interview held, and a copy of this report was provided.