complaint·March 6, 2023

CONT - PAGE 2 R1’s physician’s report dated 12/05/2022 noted that R1 had a diagnosis of dementia, was identified as having confused/disoriented behavior, and was unable to manage individual aspects of care such as bathing, dressing, grooming, and toileting. Staff interviews confirmed that R1’s assessment was done in the presence of R1 and R1’s family. The staff whom completed R1’s initial assessment supported claims that R1 ambulated within their personal home without the assistance of a walker or wheelchair and noted that R1 did not require a walker or wheelchair at the time R1 was admitted to the facility. R1’s preplacement appraisal dated 11/29/2022 documented that R1 suffered from short term memory loss, was described as having obsessive behavior, anxiety, and had occasional mis-coordination with walking. The preplacement appraisal also noted that R1 occasionally ‘lies down but gets back up… confusion with bedtime’. Staff interviews and a review of charting notes for R1 indicated that during R1’s first day at the facility, the staff mirrored R1’s routine that R1 established in their previous living arrangement to ensure a smooth transition. Charting notes indicated that R1 slept through the night on 12/27/2022, yet the morning of 12/28/2022, it was noted that R1 wandered the halls at 1:00 a.m. and that R1 was redirected back to their room. An interview was conducted with Staff #1 (S1), whom was the same staff on shift during the overnight shift on 12/30/2022. S1 claimed that during the night shift (10 p.m. on 12/27/2022 through 6 a.m. on 12/28/2022), they followed R1 while R1 ambulated through the community and re-directed R1 back to their room as needed. Throughout the day, on 12/28/2022, staff indicated that R1 was adjusting to the community. It was documented that R1 slept through the night that evening, leading into the morning of 12/29/2022. Staff interviews and a review of charting notes revealed that on 12/29/2022, R1 was visited by their family. Staff whom worked during the shift claimed that soon after R1's family left the facility, it appeared that R1 wanted to leave with their family as R1 began attempting to exit the facility. Staff claimed that they implemented several interventions to attempt to re-direct R1’s exit-seeking behavior. Charting notes indicated that R1 was ‘very energetic and walked around the unit and exit sought’, and further noted that R1 had a hard time sleeping. Staff claimed that they tried several redirection techniques and methods to decrease R1’s exit-seeking behavior and attempted to implement R1's established nighttime routine but they were not effective. A review of R1’s Medication Administration Record (MAR) and an interview with medication technician whom worked the PM shift on 12/29/2022 indicated that R1 was provided with a ‘as needed’ medication of Trazodone at 7:14 p.m., due to the claim that R1 was having trouble sleeping. Staff notes and interviews indicated that the medication was not effective. CONT - PAGE 3 S1 stated that at the start of their shift at 10:00 p.m. on 12/29/2022, R1 appeared ‘agitated’. S1 said R1 would not ‘stay put’ for more than a minute and was ‘fast walking’ throughout the unit. S1 attempted to redirect R1 and stayed in R1’s room ‘multiple times’ that night but stated that R1 would not ‘settle’. S1 said they stayed in R1’s room for a few moments and observed that around 1:00 a.m., R1 appeared to have settled in bed. As R1 did not have an assigned 1:1 caregiver, S1 was not required to sit in R1’s room or by R1’s door. S1 claimed they left R1’s room and walked into the facility dining area, which is down the hall from R1’s room. S1 said they sat down and had been sitting for a few minutes when they began to hear ‘shuffling’. S1 said that by the time they got up from the chair to respond to the noise, they observed R1 running towards the front door. S1 stated R1 was going ‘too fast’ to stop themselves and claimed that R1 fell ‘hard’ face first into the floor. S1 said that R1’s nose was bleeding, and it appeared that R1 was unconscious but breathing. S1 said that it happened too fast that they were unable to intervene to stop R1 from falling. Thereafter, S1 contacted another staff in the building, whom assessed R1 and contacted emergency services. A review of medical records indicated that R1 was admitted to the hospital and diagnosed with a fracture of the c4 cervical vertebra (fracture of the neck), a traumatic subarachnoid hemorrhage (brain bleed), and facial contusions. Per review of the staff schedule for the memory care unit, there were at least two (2) caregivers for the morning and afternoon shifts, not including medication technicians and managers on site. During the overnight shift, there is at least one (1) staff on shift. At the time of the incident, there were only seven (7) residents in the memory care unit. Staff interviews and a review of the Facility Program Plan details that the facility does not provide 1:1 supervision. An interview with a family member of R1 conducted on 1/19/2023 supported claims that the family was informed that the facility would not provide R1 with a 1:1 caregiver, yet it was discussed that staff would closely monitor R1 during the first 72 hours of R1’s stay. Staff stated if a 1:1 caregiver was discussed, R1’s family were aware that it would be an out-of-pocket expense and would have to be from an outside agency. However, as R1 was a new admission, staff were still observing R1 to best determine R1’s care needs. Information obtained from staff interviews corroborated claims that for any new admission into the memory care unit, residents are closely monitored for the first 72 hours for any noted changes of conditions and behaviors. R1’s facility care plan, dated 12/28/2022 and R1's physician's report dated 12/05/2022, indicated that at the time of admission, R1 was not identified as having the potential to wander. Yet, this was R1’s first time living at an assisted living facility and away from their family, and staff assumed that it was a difficult transition for R1, which may have triggered R1’s exit seeking behavior. CONT - PAGE 4 Based on the information obtained in interviews and record review, there is insufficient evidence to support the claim that due to lack of supervision, R1 suffered a fall. Interviews with S1 and other staff whom provided care to R1 stated that R1 continued to exhibit exit-seeking behavior throughout the afternoon and evening, and staff claimed that they followed R1 around the community and re-directed R1 as needed. Once staff felt that the behavioral management techniques were ineffective, they attempted to manage R1’s anxiety and wandering behavior with PRN medication which was ordered by R1’s physician. However, the medication was ineffective. Although R1 had continued to display exit seeking behavior that evening, S1 believed R1 to be in bed before leaving R1 in their room and sitting down in the dining area. Had R1 been knowingly walking around the facility, S1 stated they would have been with R1. The allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.