Complaint·October 21, 2025

On 08/31/2025 at approximately 9pm, R1 was assisted into bed by staff. R1 uses a wheelchair and requires staff assistance and a hoyer lift to be transferred into bed. R1 fell out of bed and was unable to reach their call pendant. R1 was found on the floor by staff the following morning, 09/01/2025. The staff was unable to lift R1 and obtained help from another staff. On 09/02/2025, R1’s responsible party indicated R1 complained of hip pain but the staff had not called 911 nor had R1 transported to the hospital. It was also noted R1 was on blood thinners. R1’s responsible party stated a hospice nurse indicated the facility had not sent R1 to the hospital because they were on hospice and had a DNR. R1’s responsible party also stated R1 may have indicated they were fine, but they were previously disoriented due to a UTI and believes they should have been checked at a hospital. Staff interviewed indicated the facility contacts hospice to assess residents on hospice who are found on the floor or have a change in condition, unless the injury was very serious such as heavy bleeding or being unconscious, which would warrant a call to 911. LPA reviewed care notes for R1 that stated 09/01/2025 11:09pm, Alert Charting, resident found on floor. The charting states R1 used their pendant, and notes bruising and swelling to left hip, abrasion to left elbow and above left eyebrow; hospice and family called; placed on alert charting. Interview with R1 revealed they do not remember how they got on the floor, or how long they were on the floor. R1 stated they could not reach their pendant, but a staff found them and assisted them. R1 stated they had a couple places with “severe pain,” including their hip, but did not know how to get pain pills. R1 stated a hospice nurse came over before 6am and examined them including range of motion tests with twisting and turning. R1 stated the hospice nurse determined there was no fracture and they would be ok until they can be re-evaluated as necessary by a doctor. A facility nurse interviewed stated staff informed them of R1’s fall when they arrived on shift. The nurse stated once they went to R1’s room around 7am, the hospice nurse was already in the room examining R1. The nurse stated R1 stated he was not in any pain, but they did have injuries to their hip and head. The staff who found R1 on the floor stated they responded to their call button around 4am, found them on the floor, and sought additional staff to help get R1 up. Staff stated they saw the left hip bruise, scratches to the forehead and a “rug burn” on the forehead, but R1 did not express any pain. Staff stated R1 was awake and talking to them, able to explain what they wanted, and said they were fine, therefore they called hospice instead of 911. Staff stated hospice arrived around 7am to assess the resident. Continued 9099-C Administrator stated even if a resident is on hospice, they should have been sent to the hospital for any strike to the head. Administrator stated despite a resident being on hospice or despite a family requesting they not be sent out, a resident with a potential head injury should be sent out. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Staff did not notify resident's responsible party of an incident. It was alleged R1’s responsible party was not notified of R1’s fall that occurred overnight between 08/31/2025 and 09/01/2025. R1’s responsible party indicated on 09/02/2025 they learned about the fall when they observed injuries on R1’s left side of face, above their eyes, on their arm and left hip. R1’s responsible party indicated on a previous hospital visit for R1, the facility attempted to contact the responsible party but was trying to call phone numbers no longer in use, and had old addresses. After this, R1’s responsible party provided a letter with updated contact information for themselves as well as contact information for another responsible party for R1. When interviewed, R1 stated no one contacted their responsible party to inform them of the fall. The staff who found R1 on the floor stated they do not know who called R1’s responsible party to notify them, but believed the Med Aide was responsible for calling hospice and responsible parties. Med Aide stated they tried to call both responsible parties a few times and the call would not go through. Med Aide stated they called the two numbers on R1’s contact information, and informed the nurse at the end of their shift they had tried calling. Administrator stated every year they send an email to responsible parties to ensure their contact information is up to date, and changes inputted get automatically updated in their system. Their system is accessible on a tablet that all care staff have access to, to ensure the most recent contact information is available. Staff interviewed indicated that sometimes families were not notified timely of incidents. Staff stated sometimes there is a breakdown in communication where they leave a voicemail, but after a shift change, the calls or follow ups are not always completed. Staff interviewed indicated manual updates for resident information do not get updated timely, mostly due to the facility being short staffed and focusing on other priorities. Continued 9099-C A responsible party for another resident was interviewed and indicated they had also not received notifications from staff for two falls a resident had sustained. LPA reviewed care notes for R1 that stated 09/01/2025 hospice and family were called due to the fall. The incident report submitted by the facility for the fall states on 09/01/2025 at 5:45am, notification was attempted to contact one of R1’s responsible parties, it states “no answer” and “did not leave a voice message.” Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed.