Complaint·July 28, 2025

According to S1, while attempting to assist R1 to the toilet, S1 and S3 had some difficulties with properly positioning the Hoyer lift sling. During this time, R1 soiled themselves. To properly clean R1, staff guided R1 to the bathroom floor using the Hoyer lift. S1 emphasized that there was no fall, no injury occurred, and no medical attention or hospitalization was necessary. As such, S1 stated that the situation did not meet the requirement for reporting to Department (CCLD). Interview with S3 confirmed the account, stating that R1 did not fall and was instead carefully lowered to the floor for safety and cleaning. S3 reiterated that R1 was not injured, and that the Hoyer lift was used throughout the transfer process. Interview with staff (S4) indicated that S4 entered R1’s room and observed S1 and S3 assisting R1 in the bathroom. S4 did not witness any fall incident but mentioned observing discoloration on R1 a day or two later, which was documented. However, this observation could not be confirm if it is linked to a specific incident. Additionally, LPA reviewed documentation showing that staff received Hoyer lift training on July 8, 2025, indicating that proper equipment usage procedures had been addressed. Based on the interviews conducted and records reviewed, there is insufficient evidence to support the allegation that staff did not meet reporting requirements. There was no indication that R1 experienced a fall or sustained any injury requiring notification to CCLD. Therefore, the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it. No deficiencies were cited as a result of this visit. An exit interview was conducted, and a copy of this report was provided.