Complaint·February 15, 2024

Page 2 - LIC9099 Regarding resident sustaining a head injury, it was reported that on 09/19/2023, R1 sustained a witnessed fall from her wheelchair in an activity room. Staff did an assessment of R1 and sent R1 to the hospital for evaluation. Medical record from the hospital reflected that R1 did suffer an injury, but based on interviews R1 leaned too far forward and fell out of the wheelchair hitting their head. Staff were unable to get to R1 fast enough to prevent her from falling. As a result R1 obtained a new cushion for their wheelchair that prevents R1 from being able to rock or lean forward far enough to fall out again. In regards to other bruising of the resident, through interviews it was discovered that staff technique in rolling and positioning the resident may have caused bruising accidentally by pulling the clothes or sheets to help position the resident. There was no other evidence of abuse taking place that would intend it was done purposely. According to interviews, and hospital records, the physician of R1 was notified of injuries when they occurred as well as the facility notifying the responsible party of R1. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.