complaint·December 15, 2023

It is alleged that the care provided to R1 resulted in their death. R1 was transported to the Emergency Department on 11/15/2021. She was admitted to the hospital on 11/16/2021. R1 passed away on 11/19/2021. The Coroner did not investigate her death. It is alleged that neglect/lack of care and supervision resulted in R1 sustaining multiple unexplained injuries while in care. R1 suffered an unwitnessed fall on 10/14/2021 and sustained an injury to their forehead. Facility staff were present in the room at the time of the fall but did not witness the fall. First aid was rendered but the facility staff did not seek medical attention for the head injury. Head injury is not listed as a cause of death. R1 did not have a history of falls at the facility and did not have any order for postural support while seated. R1 had a medical history of irregular bowl movement and it is not uncommon for R1 to go 3 to 4 days without a bowel movement. 911 was called on 11/15/2021. The facility staff report they did not observe any signs of immediate danger on 11/14/2021. We have found the complaint allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. A copy of this report is being reviewed with and furnished to the facility representative. R1 suffered an unwitnessed fall on 10/21/2021 and sustained an injury to her for head. Staff were present in the room but did not witness the fall. The facility policy for an unwitnessed fall is to call 911. The facility staff did not call for emergency medical services. We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative. Please see LIC 9099D.