complaint·January 5, 2024

Two caregivers were in the dining room at the time of R1’s fall, and two additional staff members responded to assess R1. Facility staff called 911 as R1 reported being in pain. R1 was taken by ambulance to the hospital where R1 was diagnosed with a hip fracture. Interviews with R1, staff and outside sources revealed that R1 is prone to falls due to both a medical condition and a temperament such that R1 is resistant to efforts intended to discourage R1 from attempting to walk and other fall mitigation efforts. The facility provided R1 with a pendant to alert staff when they need assistance and fall alert mats were placed near R1’s bed and chair. R1 lost the pendant and disabled the fall alert mats. Due to R1’s vulnerability to falling, staff member check on R1 every 30 minutes. Staffing the facility has been a concern since the COVID-19 pandemic. The facility had ongoing hiring efforts to replace staff that resigned. Although at the time of the incident staffing was not at pre-pandemic levels, interviews with staff and outside sources revealed that staff worked hard to meet all resident’s needs. R1’s fall was not due to either inadequate staffing or a lack of care and supervision. Based on observation and statements from internal and external sources including R1, the investigative findings are unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Karriem Jones.