complaint·July 13, 2023

9099C(1).The incident report for R1 reports that resident had an unwitnessed fall on 7/6/23 (6:30 pm) in the hallway and sustained a large lump on her head and left side of her face. Resident was sent out to ER for further medical evaluation and returned the same day. Resident was placed on 48 hours alert charting. Care Plan was last updated 2/2/23 and notes resident needs escorts to meals and activities. Physician's report, dated 10/12/22, indicates resident is ambulatory but is a fall risk. Resident does not require 1:1 supervision. Interview with Administrator confirmed that resident was sent out for medical attention immediately following the unwitnessed fall. Interview with Med-Tech staff (S1) revealed S1 was not working on 7/6/23 (6:30 pm) when resident R1 had an unwitnessed fall. S1 stated that she/staff has been working with resident's medical provider regarding resident's medications, which have been "cut back about 35%". S1 indicated that resident won't sit in a wheelchair and tries to push the chair instead and confirmed that R1 has not had any subsequent falls and gets agitated with staff easily. LPA and Ombudsman observed R1 on 7/13/23 in her room at the community. Resident was standing up behind a wheelchair as if she was going to push it. Resident initially stated she was in pain but then said she was not and was not able to provide any details as to how the bruising occurred. The incident report for resident (R2) reports that resident was sent out to the ER on 7/9/23 (8:30 pm) after being evaluated by a hospice nurse and physician, due to bruising and swollen lips and eyes. Staff (S1) stated she was working at the facility on 7/9/23 (Sunday) when resident was sent out to the ER, explaining resident had a prior unwitnessed fall on 7/6/23, in the hallway and sustained bruising on her face/lip area. S1 stated she called hospice on 7/9/23 due to the bruises appearing worse than in previous days. S1 stated resident returned to the facility on 7/10/23, in the afternoon, asserting "R1 falls quite often" and she/staff and resident's son have been working with hospice to adjust resident's medications so that medications causing drowsiness are only taken during the evening hours. S1 confirmed that resident has not fallen since Monday, 7/10/23, prior to the medication changes made on Tuesday, 7/11/23. Both the Administrator and S1 confirmed there have been no other residents who have sustained any bruising in recent weeks other than residents R1 and R2, and they were both due to unwitnesed falls. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report to Administrator.