complaint·October 20, 2023

Allegation: " Staff failed to supervise resident resulting in falls and injuries:" It was alleged that Resident #1 (R1) was not provided proper supervision, resulting in a fall. R1 had been residing at the facility since 2017. Review of records prior to R1's fall revealed that R1 did require frequent checks during the PM shift and used a walker to ambulate. R1 required assistance with most ADL care, as well as escort services to meals and activities. R1's needs and service appraisal indicated R1 required frequent reminders. On 10/17/2021, at approximately 06:30PM, R1 called for help. When staff entered R1's room, they found R1 on the floor near their restroom, but with their walker next to their bed. R1 sustained a fracture to their left ankle and was hospitalized. Staff interviews revealed that R1 was on a 2-hour check and had been last observed when they were escorted back to their room following dinner. R1 is typically escorted back to their room between 05:30PM and 06:00PM, so staff would return to check on R1 between 07:30 and 08:00PM. R1's fall occurred at 06:30PM, between scheduled checks. Staff interviewed indicated that R1 does require a walker to ambulate, but R1 would frequently forget to use the walker and forget to request staff assistance. R1's needs and service appraisal, as well as physician's report did not indicate R1 required constant supervision, only "two hour checks throughout the night." Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation that "staff failed to supervise resident resulting in falls and injuries" is deemed UNSUBSTANTIATED at this time. Allegation: " Facility is overcharging for care:" The complaint alleges that following R1's fall that R1 required additional care and supervision through a private caregiver and R1 and their responsible party must pay the cost for this service. R1's physician's report indicating R1's status post-fall indicates R1 requires a 24-hour caregiver. According to the facility's admission agreement "if you require one-on-one supervision because you are a danger to yourself or others, we may require that you obtain such supervision at your own expense." The facility assisted R1's responsible party in obtaining outside supervision services for R1. Interviews revealed that the private help was only there to supervise R1 to ensure R1 remained non-weight bearing for the duration of R1's recovery. The facility staff still met all of R1's ADL care needs as outlined in R1's needs and service appraisal. Staff interviewed indicated that the additional one-to-one was there only for reminders. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that "facility is overcharging for care" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.