complaint·August 20, 2024

Interviews with staff, R1, and outside sources revealed that R1 had been complaining about shoulder pain starting approximately in December 2021 and was receiving pain medication on an as needed basis. Communication logs revealed that R1’s physician ordered an X-ray for R1’s arm in January 2022, which discovered a fracture on R1’s arm. R1 made statements during interviews that R1 believed that the fracture was due to a childhood injury that R1 further aggravated during R1’s career. R1 denied having fallen at the facility, being mistreated by staff, being dropped during a transfer, or experiencing any incidents that might have caused the fracture. R1 made statements during interviews that R1 would have voiced any concerns or complaints regarding the treatment R1 received from facility staff and that R1 did not have any complaints or concerns regarding the facility staff. Interviews with staff and outside sources corroborated R1’s statements and denied being made aware of any complaints R1 had made about care provided by facility staff. Interviews with staff and outside sources revealed that R1 would transfer into a recliner by placing their arms behind their body and then dropping into the chair. R1’s physician and hospice staff stated that the way R1 transferred could have caused the fracture and that R1 had been cautioned against transferring in that manner. Additionally, staff and outside providers denied that R1 could have sustained the injury as the result of a fall due to R1’s inability to get up from the floor independently. Interviews with staff also revealed that prior to the discovery of R1’s fracture, R1 was independent of transferring needs but following the fracture, R1 required between two and three staff and the use of a gait belt to properly transfer. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Business Office Manager Sam Elizondo , whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).