complaint·August 20, 2025

The Needs and Services Plan documents, “R1 ambulates independently, is alert and able to make needs known. R1 is able to transfer to and from bed and chair, needs help toileting, dressing and bathing.”R1’s Individual Service Plan was updated on 07/14/2022. The plan documents R1’s diagnosis as Mild Cognitive Impairment and requires reminders from staff. R1 requires assistance with mobility/ambulation, and the plan states “RCFE staff will continue to reinforce fall precautions and will assist R1 in mobility or ambulation as needed, per patient’s request.” A review of the Special Incident Reports (SIRs) submitted by the facility revealed the following: On 09/29/2022, at approximately 11:55pm, while doing rounds, care staff found R1 on the floor in their room with a big bump on forehead. 911 was called and R1 was transported to the hospital. On 10/02/2022, the facility shift report notes R1 had a fall but was not hurt. On 10/16/2022, the SIR documents R1 had a fall in the hallway and sustained an injury to their forehead, and it was bleeding. 911 was called and R1 was transported to the hospital. On October 16, 2022, at 5:33am, R1 was transported by ambulance to the hospital emergency department (ED) with a head injury from a fall. Per the EMS report, R1 had an unwitnessed fall at the facility and was found in the hallway by staff. R1 was noted to have a hematoma to the forehead. Per EMS, R1 stated R1 thought R1 was in R1’s room and was trying to get up when R1 fell. R1 denied loss of consciousness, neck pain or back pain. No other complaints were reported at this time. R1’s initial diagnosis included traumatic head injury with multiple lacerations, traumatic injury of head with hematoma of scalp, and facial hematoma. At 7:17am, the ED notes documented, R1 has a large hematoma to forehead with bleeding controlled and bruising around left orbital (eye) and left cheek. R1 reports that R1 had been falling more often. R1 reports slight soreness to area but recently got an IV. R1 has a wound on the right shin in the late stages of healing. R1 with bruising in multiple stages of healing, history of recent frequent falls. R1’s assessment also documented a urinary tract infection (UTI). On 10/21/2022, R1 was discharged back to the facility with an order of outpatient physical therapy for continued rehabilitation of functional mobility. Upon returning from the hospital on 10/21/2022, staff ordered Home Health Services, a hospital bed, and reassured R1’s resident representative that the staff would increase the frequency of checks and encourage R1 to utilize the walker when ambulating. Staff assessed R1 after each incident and notified 911 in a timely manner. The information obtained during the Department’s investigation did not sufficiently support the allegation. While R1 did sustain falls which resulted in multiple bruises, the investigation did not provide sufficient evidence to substantiate neglect/lack of supervision. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.