Complaint·November 15, 2024

Investigator Zertuche conducted interviews on 04/02/2024, from approximately 3:00pm to 4:00pm, with R1’s resident representatives; on 05/23/2024, from approximately 9:30am to 11:00am, with administrator and staff; on 06/04/2024, at approximately 3:30pm, with R1’s conservator; on 06/07/2024, at approximately 11:00am, with Community Memorial Hospital (CMH) nursing case manager; and on 06/10/2024, at approximately 8:30am, with the home health nurse. In addition, the investigator reviewed CMH medical records, A Plus Home Health Services records, and facility file documents related to R1. A review of the facility documents for R1 revealed their physician’s report dated 03/07/2020 showed R1 was ambulatory with a diagnosis of memory loss, but able to perform most activities of daily living on their own. An incident report showed R1 was sent to the hospital on 02/13/2024 due to weakness and unresponsiveness. The following day, R1’s resident representative contacted the facility informing them R1 was diagnosed with a fractured femur. The facility conducted an internal investigation which revealed no reported incidents at the facility. There were several visits conducted by the home health agency prior to the incident but nothing of concern was noted. The facility notes and records indicated R1 sustained a previous injury in March 2023 where an unwitnessed fall was documented sustaining a broken arm. There were also notes of follow up visits to the doctor showing the injury had healed. Information reported by the administrator revealed that on 02/13/2024, R1 was not looking well, and the administrator decided to send R1 to the hospital and contacted R1’s resident representative. The following day, R1’s resident representative contacted the facility stating R1 had a fractured femur. The administrator questioned the staff and reviewed video, but there was no reported fall. The administrator denied hitting or pushing R1 and has not witnessed or heard of any of the staff members or residents hit or push R1. The administrator was surprised to hear of the fracture since R1 was able to walk without pain. Staff confirmed R1 did not walk well, as R1 shuffled their feet, but was able to get around on their own. R1 also used a wheelchair for safety. In addition, R1 was constantly supervised by staff members as R1 required assistance for most activities of daily living. R1’s room was placed near the entrance by the front office where there is lots of traffic. However, R1 was always in the activity room with the other residents and staff members. Staff denied witnessing R1 fall or be mistreated. There are cameras in the facility, but they do not record beyond 30 days, so there was no footage available for the Department to review. Continued on 9099-C According to the CMH medical records, the records documented two visits to the hospital, the first one being 03/12/2023 due to an unwitnessed fall where R1 sustained a mild humeral shaft fracture (upper arm area), right lip laceration and shoulder pain. Also found were several fractured ribs but date of injury was unknown. There were no notes of R1’s statement regarding the injury or concerns regarding the facility. The second visit to the hospital occurred on 02/13/2024 where R1 was admitted due to weakness. During the visit, R1 was also found to have a hip/femur fracture. However, the cause was unknown. Records indicated no reported fall or witness to a fall and R1 had minimal response, mostly non-verbal, with one-word responses. According to the A Plus Home Health Services records, R1 was admitted to home health services on 12/14/2022 with a diagnosis of dementia, depression, language disorder, weakness, difficulty in walking and a history of urinary tract infections. R1 was listed as a fall risk and required assistance with most activities of daily living. Notes indicated the facility was proactive in modifying the environment to enhance safety and expressed concern about R1’s balance and fall risk. Visit nursing notes indicated R1 did not verbalize any complaints about the facility but complained of persistent shoulder pain. However, R1 was able to engage in activities (hospital medical records listed no concerns regarding the shoulder). The Department’s investigation revealed there were no witnesses to the incident and facility staff members denied abuse or anything unusual. There was no history of falls except one occurring a year prior. In the recent incident, on 02/13/2024, R1 sustained a fractured hip, which was not witnessed, and was taken to the hospital for an unrelated concern when the fracture was found. R1 is non-verbal, so R1 did not report abuse or neglect, and other residents, including R1’s roommate, would not respond to questions due to their cognitive skill level. There was no police investigation for this case and there were no concerns noted on the medical records or expressed by R1’s conservator. Based on the information obtained, there is insufficient evidence to support the allegation, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.