complaint·January 28, 2025

Insufficient staffing led to severe falls: Unsubstantiated On 12/02/2024, R1 sustained an unwitnessed fall in their room. Interviews indicated, R1 pushed their pendant for help. Interviews indicated staff responded timely to R1’s pendant call. Staff assisted R1 up. R1 stated they felt a little soreness in their knees and felt a some of pain. On 12/02/2024, S1 was taken to the emergency room (ER). Medical records revealed that R1 was discharged from the hospital with a diagnosis of a fracture of sacrum without disruption of pelvic ring. Based on records review, R1 sustained (4) unwitnessed falls in their apartment. Staff would respond timely when R1 would push their pendant. Although R1 sustained a fall which caused them injury, the Department has determined that R1’s falls were not a result of staff’s lack of care or supervision. Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED . A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Call buttons are not answered timely: Unsubstantiated The department conducted interviews and reviewed records to investigate the allegation. During residents’ interview, residents stated that staff respond to their call buttons in timely manner however sometimes there is a delay in response due to staff assisting other resident’s needs. During call button log review, the department did not observe any long or extended wait times from staff to respond to resident's call button. As a result of this investigation, LPA finds allegation to be UNSUBSTANTIATED - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Report left with facility.