Inspector’s narrative
What the inspector wrote
LPA Monter interviewed staff S1-S8. S1 stated if R1 is agitated, will walk by himself/herself. S1 stated the care givers are there and will assist the R1 whenever R1 tries to walk. S1 stated that at night, R1 will try to get up and go to the bathroom, in his/her bedroom. S1 stated R1 will also sometimes go out of his/her room. S1 stated R1’s bed has an alarm that will notify staff if R1 gets out of bed.
S2 stated R1 has an issue with his/her knee and loses balance. S2 stated R1 needs assistance in walking. S2 stated staff will go with R1 when R1 walks. S3 stated R1 needs assistance walking. S3 stated R1 has an unsteady gait and uses a wheelchair or walker that he/she doesn’t like to use.
S4 stated R1 is unstable, so he/she assists R1 to ensure he/she doesn’t fall. S4 stated staff are supposed to watch R1 because he/she likes to try to walk by him/herself. S4 stated staff are supposed to assist R1 when he/she walks or a hand to keep R1 safe. S5 stated R1 is a rebellious resident. S5 stated R1 will listen sometimes and will not listen other times. S5 stated when he/she sees R1 walk, he/she will offer R1 the wheelchair. S6 stated R1 needs help with walking. S6 stated he/she has helped R1 walk a little. S6 stated that he/she has not had many interactions with R1.
S7 stated when R1 walks around, he/she has an unsteady gait. S7 stated R1 holds onto the side rail when walking. S7 stated staff are supposed to assist R1 if he/she gets up or tries to walk. S7 stated R1 will try to get up in the middle of the night. S7 stated R1 will be put in bed and then will get up and walk around. S7 stated the night shift needs that supervision because R1 is a fall risk and likes getting up at night. S7 stated the night alarm goes off at night. S8 stated R1 can walk, but its unsteady. S8 stated they are supposed to keep an eye on R1 because he/she likes to get up on his/her own but has an unsteady gait.
On March 7 & 13, 2025, LPA Monter interviewed staff S9-S11. S9 stated staff make sure they are watching R1 during their shift. S9 stated R1 wanders and is fall risk. S10 stated R1 was able to walk a little, but shaky and not stable. S10 stated staff was supposed to help R1 when he/she walks because he/she’s a fall risk. S11 stated he/she worked the night shift but doesn’t remember working with resident R1.
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Based on a review of R1’s Physicians report, dated June 3, 2024, R1 has a neurocognitive disorder.
Based on a review of R1’s Appraisal/Needs & Services Plan (ANS), dated May 11, 2023, signed on December 15, 2023. The ANS states R1 has a neurocognitive disorder. The ANS states R1 is a fall risk. R1 also has a history of falls at home. R1 uses a walker but refuses to use it at times. The ANS states R1 also wanders at times. Under Objective/Plan, the ANS states to observe fall precautionary measures: provide a well-lighted room at all times, maintain a clutter free environment, remind R1 to seek staff’s assistance at all times, monitor for any changes in functioning skills.
Based on a review of facility incident report, dated February 29, 2023, R1 sustained a fall on February 28, 2023 around 4:30am and was found sitting on the floor. Resident R1 returned to the facility after a few hours from the ER and had a right orbital fracture.
Based on review of facility incident Report, dated March 23, 2023, R1 sustained a fall around 10:45am, while walking. A staff member who was closest to R1 was unable to catch R1 as he/she fell.
Based on a review of facility Physician visit communication form, dated January 9, 2024. Attached to this communication was an after-visit summary form with stated “ER transfer patient with R Chest and R abdomen pain after probable fall.”
Based on a review of facility incident report, dated January 18, 2024, R1 had sustained an unwitnessed fall around 5:30am on January 13, 2024. Resident R1 returned to the facility to the facility late in the afternoon.
Based on a review of facility incident report, dated February 7, 2024, states at 7:30 R1 complained of knee pain. Staff gave medication and put R1 to bed. Staff walked along the hallway when he/she heard a crash sound. Staff saw R1 on the floor on his/her right side. R1 had no bumps or any redness, except for a bloody cheek.
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Based on a review of Facility incident report, dated March 7, 2024, R1 sustained an unwitnessed fall in the dining area at 7:30pm. Staff checked R1 over and there were no cuts bumps, scrapes.
Based on a review of facility incident report, dated May 13, 2024, R1 was walking and lost balance and fell on floor, at 1:20pm. Staff checked up on R1. R1 stated he only felt pain his/her butt and a little in the back.
Based on a review of facility incident report, dated May 24, 2024, R1 had sustained unwitnessed fall on 5/24/24, inside his/her room at 5:30am. R1 was bleeding on his/her forehead. Resident R1 returned to the facility the same day, around 1pm.
Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are
UNSUBSTANTIATED
. Although it is a fact that resident R1 sustained falls at the facility, there is not a preponderance of evidence to prove that the allegations neglect/lack of supervision did or did not occur.
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END OF REPORT.
