complaint·November 2, 2023

911 was called and from the time of the fall until after paramedics left, S1 stayed with R1. S1 indicated R1 informed the paramedics of shoulder pain. LPA obtained paramedics report dated 9/25/2023 at 5:22 am that indicated fall was witnessed and there was good range of motion, as well R1 declined transport to hospital and had POLST on file with comfort measures only. LPA’s Interview with S2 informed, although the paramedics helped R1 back into bed, the facility does not need assistance helping residents who fall in their rooms back to bed. LPA interviewed the Director of Health Services who confirmed the facility used to call 911 for lift assists with larger residents but discontinued the practice years ago. The investigation revealed facility incident report dated 10-2-2023 indicates the fall was unwitnessed by S2, but further investigation revealed it was witnessed by S1 who observed R1 turning at their bedside and falling. Therefore, the allegation Resident sustained a fracture due to lack of care from staff is Unfounded . This agency has investigated the complaint and has found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.