complaint·April 14, 2022

resident records, there was no indication following these falls, that facility implemented a plan of care to minimize R1’s risk for future falls. According to R1 facility records dated June 2020, R1 was “subject to fall” and required a walker for ambulation due to diagnosis of Paraparesis of both limbs. It was noted that facility staff will monitor. In addition, Staff #2 (S2) reported during the investigation that R1 had been showing decline in functioning and started walking slower; however, S2 reported that R1 refused to use walker. In addition, S2 told Department staff that S2 did not consult a doctor about R1 refusal for assistive devices. Despite staff observing change in R1’s condition, there was no indication again that facility implemented a plan of care to minimize R1’s risk for future falls. Furthermore, in September 17, 2020, due to what was identified as another fall, R1 was transported to the hospital and subsequently diagnosed with fracture of the cervical vertebrae. The allegation that, facility staff neglected R1, is substantiated. In regard to allegation #2, On 9/17/2020 at around 4:00 am, Staff #1 (S1) reported that they heard R1 get up to go to the bathroom. Then, R1 went back to R1 room but left the door open. S1 stated that this was very unusual for R1, so S1 decided to check on R1. When S1 entered the room, R1 was sitting on the floor with back leaning against the wall. S1 picked R1 up and put R1 back in bed. S1 reported no visible bruising or swelling to R1. However, S1 did not indicate if R1 was awake at the time of this incident nor was it indicated that S1 inquired with R1 as to R1’s condition immediately following the incident. S1 admitted to not reporting R1’s fall immediately to the facility administrator nor seeking medical attention or 9-1-1. S1 stated that at 11:00 am, R1 asked for assistance getting out of a chair and getting into bed. S1 stated that this was unusual for R1. S1 stated that R1 also complained of neck pain, which is when S1 decided to contact S2. It was reported that S2 arrived around 11:15 am. S1 had not called 9-1-1 prior to S2’s arrival even though S1 exhibited “unusual” behavior. S2 stated she found a “bump” on R1’s head and then called R1’s responsible party and 9-1-1. However, according to R1’s medical records, R1 was admitted into the hospital due to the fall, around 1:02 PM, approximately 9 hours after R1 initially fell. The allegation that, facility staff failed to seek timely medical attention for R1, is substantiated. Based upon the evidence discovered in the investigation, including interviews and records review, allegation that facility staff failed to seek timely medical attention for R1 is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. This posed an immediate Health and Safety risk to residents in care. See deficiencies cited on LIC 9099D. In addition, an immediate civil penalty will be assessed for violation resulting in injury. An exit interview was conducted where this report was discussed and a copy was provided to Administrator at the conclusion of the visit.