complaint·December 20, 2022

Wellness communication notes were reviewed and noted on 3/18/22, R1 was found on floor at 0710 and 911 was called. R1 returned the same day and then on 3/19/22, R1 was found on floor at 0500 and again around 1202PM, R1 had an unwitnessed fall. Nothing was noted regarding the use of walker which corroborated with the staff interview on no new instruction was given after the first fall. The review of MAR of March and April 2022 noted several medications (Miralax, Metformin, Insulin to name a few) were not given to R1 per doctor’s orders (11 days in March and 8 days in April) with no staff initials and no reasonable explanation as to why they were not given or missed. 1 Out of 1 staff interviewed stated MAR would specify the reason why a resident missed the medication. The Department has investigated the above allegations. Based on records reviews, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $10,000.00 for violation resulting in serious bodily injury is pending review. Exit interview was conducted with JL. This report and LIC9099-D were provided to JL. Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation finding and met with Executive Director Lola Bullock (ED). On 05/05/2022, the Department received a complaint with the above allegation. On the same day, the Department conducted an initial investigation visit. Resident's file, care plan, incident reports, resident physician report, appraisal needs and service plan, and admission agreement were obtained. On 11/01/2022, LPA tested the motion detector in randomly selected rooms and interviewed ED. The motion detector was deemed functioning. ED stated the facility partners with Safely You who maintains the camera system with motion detector to evaluate the impact of artificial intelligence in detecting falls. ED stated Safely You monitors the camera system, uploads the fall videos, and notifies the facility through phone calls and emails on resident’s fall. ED stated the facility staff will immediately help residents who fell when staff received phone calls or emails from Safely You. On 11/01/2022 and 11/03/2022, LPA interviewed Safely You Clinical Success Manager (AH) who stated that Safely You has a 24/7 team monitoring the camera system. The team will send alarm notifications, emails, and calls the facility to notify the fall of resident and upload the videos. AH also stated that Safely You will fix any problem or issue with the camera system. For the fall of R1 on 3/19/2022, the camera system did not capture the fall. ED stated the following statements were provided to residents on the use of the camera system: "The camera system will be a supplement to the fall procedures, not a replacement." ; "The camera system is not 100% accurate, and falls could be missed even with the system in place due to technical issues." And “Cameras will be located solely in the bedroom and primary camera focus will be around the bed area.” Continued on LIC-9099-C. Pahe 2 of 3. The admission agreement and documents on Safely You motion detector were reviewed and noted they corroborated with the ED and AH’s statements that Safely You is responsible for the motion detector and that this system may not capture every fall due to the field of view limitation. Based on observations, documents review, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with JL. A copy of this report was provided to JL. The review of hospital records noted on 3/18/22, R1 was taken to the ER due to unwitnessed fall. The discharge care includes the importance of assistance with ambulation and walker use. It was further noted that on 3/19/22, R1 arrived at 1330 hours because of unwitnessed fall with suspected head strike. X-ray showed right femoral intratrochanteric fracture. R1 underwent hip surgery and was discharged to SNF on 3/23/22. Between 06/29/2022 and 09/17/2022, the Department interviewed 4 memory care unit residents including the victim (R1), a family member (FM), and 6 staff including the Executive Director (ED). On 11/1/22, additional 1 staff and ED again were interviewed. 4 Out of 4 residents were unable to provide details or information on falls. ED, during interview, admitted to receiving the discharge papers on 3/18/22 fall. Per ED, after the first fall, clinical team (med tech, nurse, wellness coordinator) would contact family for a mediation plan. ED, however, was not able to produce any document to prove this occurred. ED stated R1’s existing plan of “observe closely” was appropriate as other plans were in place like half bed rail, Safely You detector, and hourly check. 6 Out of 6 staff interviewed stated fall risk residents are checked every hour and there was no new instruction other than to monitor closely for R1 after 3/18/22 fall. The review of R1’s Appraisal Needs and Services (ANS) plan dated 2/3/2022 noted under Physical, it reads: “Fall risk, check resident; Physical – fall risk, escort/assist to/from activities and dining room daily.” Under Redirection and Guidance, it reads “staff provide additional interventions to manage exit seeking behavior because resident is a high fall risk. Redirection for all 3 shifts.” There was nothing noted on the use of walker. ANS was not updated to include the use of walker as instructed on the discharge summary care of 3/18/22. Continued, see LIC 9099-C. page 2 of 3.