complaint·August 28, 2024

CONTINUED FROM LIC9099 Based on records reviewed and interviews conducted, it was determined that resident R1 was admitted to the facility on or around September 30, 2020. Per the physician report established upon admission, resident had an indication of dementia as well as a colostomy, was displaying confusion/disorientation and was not receiving hospice care at the time of admission. Due to an initial change in condition an updated physician report dated March 3, 2021 was established by R1's primary care physician to reflect the resident's incontinence status. Final updates were observed in August 2021 after R1 was admitted onto hospice care with a terminal diagnosis of hypertensive heart disease. The hospice admission agreement was also reviewed and indicates a date of admission of August 6, 2021. The progression of R1's condition was confirmed to have been well established and documented throughout their admission. Multiple fall episodes were confirmed to have occurred, however witness interviews established that appropriate preventative measures had increasingly been put into place, with the prescription of a hospital bed, fall pads, and culminating in the provision of a full-time one-on-one presence which was confirmed to be in effect at the time of the August fall incident. Therefore, even though multiple falls are confirmed to have occurred, evidence gathered does not corroborate the fact that they could be attributed to negligence or failure to provide care and supervision from facility staff. As a result, the allegation is found to be Unsubstantiated, meaning that 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. An exit interview was conducted and a copy of this report was provided to a facility representative.