complaint·November 6, 2024

Allegation: Staff neglect resulted in resident falling. On 11/6/24, LPA Felisa Shirley reviewed resident’s facility file. Upon review of C-1’s Physicians Report, C-1 is a fall risk. LPA reviewed a Special Incident Report in which on 10/31/24, C-1 began slipping from soap during a shower. C-1 began sliding so caregiver guided resident to a sitting position on the floor of the shower. Med Tech and Wellness director were notified. C-1’s family was also notified that resident was assessed, there was no fall, and he was not in any danger. Family stated that they did not see any need to send him to the ER. On 11/6/24, LPA toured facility and went to client’s room and observed that there was no plastic chuck placed on top of the sheets. LPA did observe a large bath towel folded and placed on the bed sheets, on the side of the bed that C-1 sleeps on to avoid sliding and falls. LPA did not observe any special incident reports that reported any falls. LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, does staff neglect result in resident falls? Of those interviewed, 7 out of 7 answered no. LPA interviewed Client-1 thru Client-7 (C-1 thru C-7). LPA asked, have you had any falls due to staff neglect?” Of those interviewed, 7 out of 7 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff neglect resulted in resident falling,” therefore the allegation is unsubstantiated.