complaint·October 6, 2021

Interviews stated that resident #1 (R1) had a fall on or around 03/23/2020. File review on 10/06/2021 revealed that R1 had fallen on 03/21/2020 in the afternoon shift. R1 was getting up from the couch in the living room. File review and interviews also confirmed R1 was receiving hospice services before the fall. R1 had a hospice diagnosis of Alzheimer’s Disease unspecified. Facility staff immediately called hospice agency to report and monitor R1. R1 was regularly monitored and seen by a hospice nurse 2-3 times a week. Interview with R1 could not be conducted as they passed on 09/20/2020. On 08/12/2021, LPA obtained photographs of R1 from facility file between the dates of 03/23/2020 and 03/30/2020, which revealed puffiness and yellow, green, red and purple discoloration on the right side of the face above and below eye. Interview on 08/12/2021 with staff #1 (S1) revealed that R1 would often wear non-fitting clothing thus causing R1 to stumble. Review of R1’s facility file and chart notes revealed that following the fall, R1 was placed on hourly checks and was given as needed medication for pain management. Review of R1’s hospice notes on 10/06/2021 confirmed R1’s fall on 03/21/2020 and hospice visit on day of and days following of fall. Hospice note on 03/30/2020 states that “R1 continues to walk wit eyes closed and needs constant redirection.” Based on the evidence gathered, there is insufficient evidence to prove the alleged violation occurred due to staff neglect and lack of supervision. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted. A copy of this report provided to BOM via email.