Complaint·April 30, 2025

Based on R1’s physician’s report dated October 2023, R1 was able to communicate R1’s needs and follow instructions; however, R1 was not able to independently transfer to and from bed. R1 utilized the call pendant when R1 needed help; most of the staff verified that R1 knew how to use the call pendant, but others reported that R1 would forget to use it. R1 had a history of previous falls that had not resulted in any injuries. Interviews with caregivers, medication technicians and resident care coordinator reported R1 received fall-risk checks and status checks. One caregiver reported checking on R1 every fifteen (15) to twenty (20) minutes, whereas other caregivers checked on R1 every one or two hours. Additional staff reported that they would escort R1 to the dining area, placed R1’s walker near R1, and assisted R1 to a recliner, and or bed before leaving R1’s room. On July 20th, 2024, staff checked on R1 between 0600 and 0700 hours and reported R1 was not ready to get up yet. At 0745 hours, the facility’s Resident Care Coordinator found R1 on the floor. R1 reported pain and hitting R1’s head. The care coordinator then summoned emergency medical services and R1 was transported to the hospital for further evaluation. Interviews and review of hospital records confirmed R1 lived at the facility until R1’s fall on July 20th, 2024, when R1 sustained several fractures such as fractured rib, right shoulder and right scapula fracture, right wrist fracture, right clavicle fracture and right elbow fracture. A CT scan of R1’s head and cervical spine showed no evidence of fracture or brain bleed. R1 was later moved to a board and care, after the facility determined they would not be able to meet R1’s needs post fall. A review of R1’s hospice records noted R1 was placed on hospice care on July 22nd, 2024, due to senile degeneration of brain and noted comorbidities as dementia, hypertension, hyperlipidemia, Type II diabetes, gout, deep vein thrombosis, osteoporosis, obesity, venous stasis ulcers. A medical examiner’s report was requested, but there was no autopsy report available. Review of R1’s death certificate noted R1 expired on August 14, 2024, at approximately 0900 hours and R1’s cause of death was senile degeneration of brain, not elsewhere classified. There were no other underlying factors that contributed to R1’s death noted. Several contact attempts were made with R1’s Primary Care Physician (PCP) but were unsuccessful. Contact was made with a source, who assisted with providing information on behalf of R1’s PCP. R1’s PCP had not seen R1 since October of 2023, therefore, the PCP would not have known R1’s most recent mobility/ambulation status pertaining to R1’s falls. (See additional LIC 9099-C for continuation of report.) Based on the evidence obtained, R1’s fractures were not the cause of R1’s death. There was insufficient evidence to prove that facility neglected, or did not provide care and supervision to R1 that resulted in R1 falling on July 20, 2024. The allegation was unsubstantiated. An exit interview was conducted with Lopez, to whom a copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided.