complaint·October 4, 2022

At the hospital, it was later determined that R1 suffered from a brain bleed, which was separate from the brain bleed R1 had just been previously hospitalized for. Therefore, based on record review and interviews conducted, the allegation " Facility did not contact medical services for resident." 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. Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to LVN Deanna Lewis during the exit interview. and their subsequent fall, such as the fall mat and additional staff checks. Due to the short period of time between R1's return to the facility and their next fall which resulted in another hospitalization, there is not enough evidence to suggest that the facility did not take additional reasonable safety measures to attempt to prevent additional falls. Interviews conducted revealed that the facility was attempting to get R1 placed on hospice prior to his discharge from the hospital on 9/28/22, so that R1 could have the additional support of a hospital bed with guard rails (which Title 22 Regulations require a resident to be on Hospice to have). Therefore, based on the measures taken by the facility, the short period of time that the resident was back at the facility, and lack of additional evidence, the allegation " Facility did not provide a safe environment for resident." is UNSUBSTANTIATED. 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 with LVN Deanna Lewis and a copy of this report was provided.