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32 | It was alleged that on 07/06/2025 around 11PM, Resident #1 (R1) fell out of bed and was found by staff on 07/07/2025 at 5AM despite having staff requirements to check on residents every 2 hours. R1 then sustained multiple skin tears due to trying to get up from the floor and injuring arms. LPA interviewed ED, the Health and Services Director (HSD), and two (2) care staff and all interviews revealed that R1 was not placed on frequent monitoring or status checks that require R1 to be checked every 2 hours. Staff stated that the amount of checks depends on the resident’s condition and their care needs and that there is no standard requirement for all residents to get checked every 2 hours. LPA reviewed R1’s records and observed that R1’s physician’s report signed and dated on 05/27/2025 documented R1 as nonambulatory and unable to transfer to and from bed. R1’s assessment and care plan that was updated on 07/06/2025 and signed by R1’s responsible party documented R1 as a “moderate” fall risk and “requires status checks daily for safety or recent change of condition” as well as “requires standby assistance and cueing for transfers.” The Department received an incident report on 07/15/2025 stating that on 07/07/2025, R1 had been found on the floor by staff at 06:30AM with a large skin tear on their right arm after an unknown amount of time on the floor and emergency services were called immediately after R1 was found. LPA reviewed R1’s updated assessment from 07/21/2025 and signed by R1’s responsible party on 07/23/2025 which documents R1 as a “high fall risk” with “status checks each shift for safety or recent change of condition.” LPA interviewed R1’s responsible party and no concerns supporting the allegation were mentioned. Interviews supported that R1 presses their pendant often which results in R1 getting checked multiple times a day, even though the care plan from 07/06/2025 only required one (1) daily check. LPA reviewed call log history and response times for R1’s pendant and observed that on 07/06/2025, R1 pressed their pendant 23 times with the last two calls at 09:05PM (response time of 12.10 minutes) and 09:50PM (response time of 11.60 minutes). The day before R1’s fall on 07/05/2025, R1 pushed their pendant 29 times. The longest response time observed for R1 was on 06/17/2025 with a response time of 62.80 minutes, however, most response times were under 15 minutes. ED and HSD also stated that any response time for any resident that is over 15 minutes gets flagged and in-service trainings for pendant response times get provided to all staff. Resident interviews conducted did not reveal concerns about the care provided or staff responsiveness. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Resident sustained multiple skin tears due to staff neglect” is deemed UNSUBSTANTIATED at this time.
No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
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