complaint·September 28, 2022

was found on the floor by facility staff on 5/14/2020 between 6:00 PM and 7:00 PM. Once found on the floor, R1 was assessed by staff for injuries, and the only injury noted was a red bump on R1’s forehead. According to interviews conducted, R1’s spouse was contacted at approximately 7:00 PM and informed that R1 had been found on the floor. Records indicate that, around the same time, the hospice agency which provided services to R1 was called and notified that R1 had been found on the floor. The hospice agency was informed by facility staff that it appeared that R1 had no injuries other than slight redness on the forehead, and facility staff declined a need for a nursing visit at the time. Records reflect that the hospice triage nurse encouraged staff to call the hospice agency with any other issues, concerns, or changes in R1’s condition, if any occurred. Evidence reflects that, subsequently, at approximately 7:45 PM, facility staff called the hospice agency and advised that R1’s spouse requested a visit from the hospice nurse on the same night. A hospice nurse visited R1 at 8:19 PM on 5/14/2020 and noted that R1’s vital signs were within normal limits. It was also documented that the nurse was able to move all of R1’s extremities without difficulty, and there were no obvious signs of injury. It was noted that R1 had a red area in the mid forehead, and facility staff were advised to monitor R1 for any changes in level of alertness. Based upon a lack of evidence yielded during the investigation to conclude that facility staff delayed for an extended period of time in contacting R1’s hospice agency and lack of evidence of any injury resulting from an alleged delay in R1 being seen by the hospice nurse, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Kandy Franklin, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the Executive Director at the conclusion of the visit. Kandy Franklin’s signature on this report acknowledges receipt of copies of the rights and report.