complaint·October 24, 2023

The investigation consisted of the following: Regarding allegation: Resident sustained a fracture while in care. It is alleged that R1 fell at the facility, which resulted in a fractured shoulder. Per incident report obtained, dated: 03/03/22, it is noted that facility reported to the licensing agency about R1 falling off R1's wheelchair on their left side, while being escorted to the dining room by staff and was attempting to reach to grab an object, while passing by. It was indicated that R1 was assisted up, observed for injury, and first aid was rendered. R1's family and hospice agency was notified. Per x-ray records obtained, it was noted that a mobile x-ray was completed by R1's hospice agency on 03/09/22, indicating that R1 had a "left humeral surgical neck fracture and AC separation". There is no indication on the report that the fracture was sustained due to a fall the resident had. Per interviews conducted with S1, S1 witnessed this fall and immediately notified R1's family, physician, and hospice care. S1 stated that R1 was assessed for injuries and did not have any. S1 also stated that R1 did not exhibit symptoms or express to be in pain at that time. S1 stated that R1 expressed pain a few days after, during a nurse visit from Hospice, and the hospice agency requested a mobile x-ray to be completed at the facility at that time. The x-ray showed a fracture, but it was not confirmed if it was due to the fall. Per S2, S2 recalls R1 getting diagnosed with a hairline fracture, however denies it occurring at the facility. S2 believes it was deemed to be an old fracture, but R1's family insisted it was new. (3) of (5) staff interviewed denied the allegation. Per R1's Physician's Report, Pre-Placement Appraisal, Needs and Services plan, and Current Appraisal, R1 was wheelchair bound and had a speech impairment due to diagnosis of hemiplegia and hemiparesis. There was also no indication that R1 had a history of falls. R1 required two-person assist for transferring, but was able to propel self on their wheelchair. (4) of (4) residents interviewed could not corroborate the allegation. Based on the interviews conducted, observations and files reviewed, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. During the visit, no deficiencies were observed or cited. An exit interview was conducted with Cluster Nurse, Kim Mims and a copy of this report was provided.