complaint·September 11, 2025

A review of R1’s falls while residing at the facility revealed the following: on 01/21/2021, R1 reported R1 lost balance and fell back, R1 declined hospitalization; on 06/25/2021, R1 sustained a fall which resulted in a brain bleed, and R1 was admitted to a skilled nursing facility from 06/28/2021 to 07/17/2021; on 03/19/2023, during a home visit, R1 fell and sustained a split in ear, requiring stitches; and for the incident in question: on 08/02/2023, R1 was found on the bedroom floor bleeding from the back of head, and was hospitalized. Once at the hospital, R1 was found to have sustained bilateral skull fractures with bleeding in multiple areas, which required emergency surgery. R1 died in the hospital on 08/11/2023. R1’s cause of death was intercranial hemorrhage complicated by cerebral edema and acute respiratory failure. There was no autopsy performed. Information obtained from interviews with medical personnel revealed that the 08/02/2023 CT scans showed that R1’s fractures were all acute, without indication of healing in progress. R1’s injuries might be explained if R1 had fallen multiple times within a short period of time, but the facility did not report multiple falls; only a single fall was reported. R1 was confused upon AMR’s arrival and could not provide an explanation about what had taken place. A review of R1’s death certificate documented R1 died at 6:31pm on 08/11/2023. The cause of death was subdural hematoma from blunt force head trauma with pneumonia as a contributing condition. The manner of death was listed as an accident from an unwitnessed mechanical fall in R1’s facility bedroom at 12:22pm on 08/02/2023. Upon facility admission on 01/16/2021, R1 was ambulatory with a walker due to balance issues and was a known fall risk. Despite this, R1 was deemed independent with all activities of daily living and did not require special or overnight supervision. R1 sustained two documented falls before 08/02/2023 while residing at the facility. In response to R1’s 06/25/2021 fall, during which R1 was admitted to a skilled nursing facility from 06/28/2021 to 07/17/2021, the facility was unable to produce an updated service plan or reassessment indicating how R1’s fall risk would be addressed, and the facility’s Wellness Director at that time could not recall what the facility did to address it. The facility informed R1’s primary care physician (PCP) on 07/17/2021 that R1 returned to the facility with new medications, and and the PCP replied on 07/20/2021 with medication reconciliation. Similarly, following R1’s 03/19/2023 fall while on a home visit that resulted in a split ear, the facility did not provide proof of reassessment, but the facility did fax R1’s hospital discharge records to the PCP, who instructed the facility to continue with R1’s current plan of Continued 9099 C... care and directed R1 to increase fluid intake and decrease ambulation when feeling weak. An interview with the PCP revealed they had no new recommendations for R1. The PCP reported physical therapy was last ordered in 2016, and while R1’s facility falls were known, R1 was stable and was walking 2-3 miles a day at the facility. The Department’s investigation revealed that R1’s bedroom laminate flooring was in disrepair and that the facility was aware of it at least two months before the present incident. Interviews with resident and staff revealed some areas between laminate planks in the center of R1’s bedroom had lifted, and that R1 complained about it. The facility Maintenance Director acknowledged R1 had asked for the floor to be repaired, but the repair did not occur until after R1 left the facility. The official work order for the repair was not put in until 08/14/2023. While it is possible R1 tripped over the damaged laminate floor on 08/02/2023, there is insufficient evidence to prove that the floor, or the absence of reappraisals, contributed to R1’s 08/02/2023 fall. Based on the assessment made by medical personnel R1 would have sustained at least two points of impact to cause these injuries. R1’s assigned facility caregiver (S1) heard one single thump sound from R1’s bedroom on the afternoon of 08/02/2023. Another resident witnessed the fall and reported they saw R1 fall back from a standing position onto R1’s bedroom floor. The Wellness Director, the resident witness and the AMR Paramedic and EMT stated there was blood on the footboard or bedpost of R1’s bed. R1 also told a hospital staff member that their injuries were the result of a fall. Based on this information, the allegation that R1’s injuries and subsequent death were the result of something other than a ground level fall is therefore deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued to Office Manager Nicole Aguiano