complaint·September 28, 2023

According to interviews, R1 had multiple abrasions on both knees, toes, right elbow, and right hip. Care staff were not able to recollect falls or how R1 sustained multiple injuries. R1 has history of falls, but no documented falls noted at facility. The Department reviewed R1's physician's report. Physician's report indicated R1's primary diagnosis is dementia and is confused/disoriented. R1 has visual impairment and has wandering behavior. According to R1's service plan, R1 requires assistance with using the bathroom. R1 uses incontinence products and will remove their depends and urinate on the floor or on bedding. Frequent checks are required throughout the night to ensure that R1's beddings are dry and that R1 has not urinated on the floor. Facility staff is to provide assistance to and from dining room and or community activities as needed due to memory impairment and physical impairment. R1 uses a wheelchair. R1 has fallen in the last twelve months. The Department interviewed a total of eight (8) facility staff. Interview statements received from six (6) staff indicated, they have observed R1's injuries but have no knowledge of how R1 sustained injuries while in care. Interview statement received from the staff that reported the unwitnessed fall indicated, staff conducted rounds to check on R1 and observed R1 on the floor in the bedroom. Staff assisted R1 into bed and observed a scratch on R1's back. Staff reported the unwitnessed fall to the Med Tech. Med Tech reported the incident to management and R1's responsible party. Interview statement received from ED indicated, staff observed scratches and bruises on R1. The fall may have occurred during the NOC shift and injuries were observed in the morning. There were no signs of trauma. R1 was not sent to the hospital for an evaluation. R1's primary care physician was notified along with R1's RP. A nurse practitioner was at the facility to evaluate R1 and ordered an X-ray on 4/7/2023. Interview statement received from Health and Wellness Director, Ayana Allison, indicated the facility is unsure when the incident occurred. It may have occurred at night on 4/3/2023 or in the morning on 4/4/2023. Management was notified in the morning of 4/4/2023 of the fall incident. The fall is considered unwitnessed due to staff not knowing how R1 fell, the time of the fall, or the date. R1 did sustained injuries while in care; however, after a thorough investigation, there was no evidence to suggest that the facility was negligent in their care and treatment of R1. Due to the information above, CCL finds the allegations 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 conducted with Executive Director, copy of report was provided via email.