Complaint·May 4, 2023

The interview of facility staff members revealed that a few of the falls R1 had throughout the years were due to them doing things independently and not asking for help. The interview of facility staff members revealed that R1 resided in assisted living and did not require additional room checks. Assisted living residents are checked by their caregiver every two (2) hours unless a pendant or pull cord is activated. Department staff interview with R1 revealed that their first fall at the facility resulting in a fracture, was their fault because they were walking too fast while using their walker. R1 stated that they could not get off the floor on the second fall (which also resulted in a fracture). R1 could not provide the date of that fall, nor did R1 remember what they were doing when they fell. However, when asked if they called for assistance, R1 responded, "they did not need to because, at that time, they did things on their own". Department staff file review revealed that R1 received emergency and continuous medical care until they recovered from their injuries. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #2 “Staff caused resident to fall resulting in an injury”. The allegation alleged that sometime in February 2020, resident # 1 (R1) returned to their room from lunch and used their walker with staff # 3 (S3) as an escort. The allegation alleged that R1 asked S3 not to let them fall because they felt unsteady. S3 let go of R1 to open the door, and R1 fell. Department staff interview with the reporting party (RP) revealed that R1 sustained a cut on their left knee and some soreness. Department staff interview with R1 revealed that S3 let go of them for a second, and they went down. R1 was unable to provide further details about this fall. Department staff interview with S3 revealed that on February 18, 2020, S3 was escorting R1 back to their room from lunch. S3 stated that R1 was using their walker, and when they got to their room, R1 stated they felt dizzy and tired. S3 described R1 as falling as their head and body tilted to one side. S3 stated they responded immediately, placed their arm around R1 as if hugging R1, and guided R1 down to the floor. S3 stated that R1 did not hit the floor because they could lay them down. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation # 3 “Staff failed to respond to residents’ alerts in a timely manner”. The allegation alleged that on April 11, 2017, R1 pushed their call button and waited for over 15 minutes for assistance. LPA Nickolas’ review of the facility log report on April 11, 2017, revealed that R1 activated their call button nine (9) times, and the facility staff responded in less than 15 minutes seven (7) out of (9) times. Two (2) times, facility staff responded long than 15 minutes; facility staff responded in 18 minutes at 3:01 p.m. and 16 minutes at 8:35 p.m. The allegation alleged that on April 9, 2020, R1 was left unattended in the bathroom for over 20 minutes. The allegation alleged that R1 pressed their call button several times. LPA Nickolas’ review of August 9, 2020, facility log report revealed that R1’s call button was activated three (3) times. The facility staff responded in two (2) minutes the first time the call button was activated on April 9, 2020. One (1) minute the second time the call button was activated on April 9, 2020, and eight (8) minutes the third time the call button was activated on April 9, 2020. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation # 4 “Staff mishandled resident’s medication”. The RP alleged that the facility misplaced R1’s medication and could not find it until two (2) days later. LPA Nickolas’ reviewed R1’s Medication Administration Records (MARs), which revealed that R1’s medication was administered per the physician’s orders. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #5 “Staff failed to assist resident with toileting needs” The allegation alleged that on July 29, 2017, R1 was taken to the restroom and sat on the toilet after pushing their call button for 35 to 40 minutes for the facility staff to return to assist them. LPA Nickolas’ reviewed the facility log report on July 29, 2017 and revealed that staff responded to R1’s call button in less than 10 minutes. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #6 “Staff failed to ensure residents were properly fed while in care”. The allegation alleged that on February 28, 2018, R1 did not receive breakfast and pushed their call button to inquire. Facility staff arrived, and R1 reported they missed breakfast, and the facility staff left and never returned. The allegation alleged that on March 19, 2020, R1 pushed their call button to report they did not get lunch. When unknown facility staff arrived, and R1 informed them that they did not receive lunch, R1 was advised that lunch was over. The unknown facility staff offered R1 fruit but did not bring R1 the fruit requested. LPA Nickolas’ interview with staff # 4 (S4) revealed that if a client cannot make dining services, the meal is held for them unless the client declines to eat. However, facility staff will also provide food to clients in care whenever a client announces they are hungry. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and copy of this report was provided. Based on the evidence gathered during the investigation, the above allegation 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. An exit interview was conducted where a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provided.