Complaint·December 12, 2022

LPA interviewed R1 who stated the facility took good care of them, but was unable to provide additional information. LPA reviewed R1’s Resident Appraisal (LIC603A) dated 12/31/19, R1’s Appraisal/Needs and Services Plan (LIC625) dated 01/03/20, and R1’s Physician’s Reports (LIC602A) dated 12/31/19, 09/15/20, 02/21/22, and 06/22 which indicate that R1 has Dementia, is non-ambulatory, has a history of falls, and is considered a fall risk. LPA reviewed an Unusual Incident/Injury Report (LIC624) dated 07/04/22 which states that on 06/30/22 R1 tried to get up from their wheelchair, fell forward, and suffered a cut to their forehead. LPA reviewed an Unusual Incident/Injury Report (LIC624) dated 08/03/22 which states that on 07/29/22 R1 lost consciousness while on their wheelchair and suffered a cut to their forehead. This fall was investigated in connection with Complaint Control No. 22-AS-20220729170339. LPA interviewed facility staff who stated that on 11/22/22 R1 was in one of the front common areas on a couch, R1 thought a family member was there and tried to get up to see them, but slid off the couch and hit their head on the armrest of the couch, and that this incident was witnessed with staff present. LPA interviewed AD who stated that this incident was not a true fall because R1 slide off of the couch as opposed to falling while walking or standing, that R1 was not injured, that the facility offered to take R1 to the hospital via ambulance to ensure that there were no injuries or medical conditions relating to the incident, but that R1’s family decided to take R1 to the hospital themselves. AD stated that R1 was in the front common room on 11/22/22 as a fall precaution because residents in that room are closely observed by staff, but that R1 was not considered to be at a particularly high risk of falls at the time and had been doing well recently. LPA inspected the front common room and confirmed that this is where residents who are fall risks are observed closely by staff. After the incident on 11/22/22, AD and R1’s family discussed possible alternative placement for R1 due to R1’s fall risk, but R1’s family wanted to try medication changes and wanted to keep R1 at the facility. LPA interviewed R1’s family who stated that the incident on 11/22/22 was the result of R1 becoming agitated because R1 believed a family member was there to visit them when that was not the case, that R1 was not seriously injured during the incident, that R1’s family wants to keep R1 at the facility and a different facility would be a new environment that could lead to increased agitation, that R1’s family has no complaints about the facility or the care and supervision R1 receives there, and that R1 was placed on a new medication after 11/22/22 to help with the agitation. LPA reviewed R1’s Medical Records dated 12/01/22 which show a new psychotropic medication was prescribed to R1. LPA reviewed R1’s Medical Records dated 11/22/22 which state that R1 was diagnosed with a “Fall in elderly patient” and “Cephalhematoma” but that no other injuries were noted. AD stated that the facility is currently taking the following precautions and measures to address R1’s falls: a new medication for agitation; a scheduled evaluation to assess the effectiveness of the medication; home health checks on R1 once or twice a week; a behavior log to track R1’s behavior and fall risk; 1-on-1 supervision as necessary and approved by the family; calling R1’s family to speak to R1 when necessary to ease agitation; and keeping R1 under close observation. However, AD stated that if R1 continues to have falls, R1 may need a higher level of care than the facility can provide and AD will work with R1’s family to find new placement. While R1 had a recent fall at the facility, the investigation did not corroborate lack of care and supervision by the facility in connection with the fall. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was left at the facility.