complaint·November 22, 2022

Staff reported that R1 had a history of falls but no prevention plan. R1 had only one documented fall at the facility, with the reason for emergency evacuation to the hospital being listed as "weakness." R1 was diagnosed with a fractured femur at the hospital. Information provided by the facility did not match with the transcript of the 911 call nor the ambulance records. Staff that reportedly assisted with the fall claimed that they did not work on the day that the fall took place. Administrative and medical staff at the facility provided information regarding the fall, but were unable to remember the fall when re-interviewed. Administrative and medical staff reported that R1 needed a higher level of care than they were able to provide. On an unknown date, facility staff member (S1) witnessed R1 on their bedroom floor and assisted them up. S1 documented that R1 was unable to move their hand and was unable to sit. A separate staff member (S2) reported that they were concerned about R1 because R1 was not eating. S2 determined that R1 needed medical attention, but R1 refused to go to the hospital. R1 was sent to the hospital 2 days later because they were not able to move, sit, or eat. Ambulance records indicate that R1 had been weak for 2 days. The information reflects that staff were aware and were concerned that R1 needed medical attention, but did not send him to the hospital in a timely manner. The Department has conducted an investigation of the above allegations. Based on interviews and records review, 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. Exit interview conducted with Medical Technician Ivonne Chavez. A copy of this report, along with the facility's appeal rights were provided.