complaint·June 30, 2022

Record review and interview with the care director revealed the 1:1 caregiver called out sick on 3/4/21 and also informed on 3/4/21 that R1 had a fall on 3/3/21 due to tripping over R1’s walker. Based on care plan obtained R1 is a fall risk. Care notes for 3/4/21 indicate that R1 was not showing any signs of discomfort. On 3/5/21 care notes indicate R1 was restless at 1am and observed coming out of room multiple times, re-directed back to bed and PRN given. R1 reported having leg pains while sitting up at 8:30am on 3/5/21, med-tech administered PRN at 8:37am (no effect) and called hospice to inform. At approximately 10 am resident complaining of increased pain but not due for PRN. Faciltiy notified POA R1 would be sent out to ER due to pain, identified. POA arrived to facility and took R1 to own home and later called hospital and patient was transported to ER. Complaint also indicates R1 sustained a fractured right hip. R1 never returned and was discharged from facility. R1 passed away on 3/13/2022, death certificate was obtained and no indication of hip fraction. LPA obtained medical records from 3/5/21 hospitalization which indicates right hip fracture. Based on LPAs investigation R1s injury was not unexplained and mostly likely caused from a fall. Although the allegations above 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 .