The investigation revealed the following: Regarding the allegation "Staff refuse to assist residents in care," it is being alleged staff will not assist their residents if they fall regardless of injury or not. It is alleged that if a resident slides from a chair onto the floor, staff will not assist the resident. Staff will call 911 and leave the resident in the place where they were found and they will have 911 assist the resident. Record review revealed that a total of eleven resident falls resulting in 911 calls (averaging about three per month) occurred between November 2023 and February 2024. Six out of six staff interviews indicate that the protocol is for staff to call the MedTech or Supervisor who will then call 911 for unwitnessed and serious falls. The facility’s Fall/Emergency Response Policy and Procedure (updated 07/15/24) revealed that staff is to avoid moving the resident, except to protect them from further injury. Then Management will complete an assessment and may allow resident to be assisted up to a chair if there’s no head trauma, no loss of consciousness, resident denies pain, has a full range of motion, and is alert. Interview with the Executive Director indicated that 911 is called for memory care residents and assisted living residents may accept or deny a 911 call. If the paramedics arrive, the power of attorney may authorize or deny paramedic transportation. The Executive Director indicated that staff have been trained on the policy and procedure. Five out of six staff interviews indicate they have been trained to address resident falls. Three out of six resident interviews indicated caregivers assisted initially to assess and then called 911. One out of six resident interviews indicated that the caregiver gave the resident verbal prompts how to get up but did not provide physical assistance. All four residents who reported fallen indicated that the caregivers assist and quickly assess to determine if 911 needs to be called.

Regarding the allegation “Staff refuse to assist residents in care," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

Continue to LIC9099-C.

The investigation revealed the following: Regarding the allegation "Conduct inimical," it is being alleged that staff will call 911 when a private ambulance would be more appropriate, but staff stated they do not know how to call for a private ambulance. It is also being alleged that staff will ask paramedics to perform medical interventions that do not fit their medical control guidelines. It is alleged that the facility inappropriately uses 911 services. Six out of six staff interviews indicate that the protocol is for staff to call the MedTech or Supervisor who will then call 911 for unwitnessed and serious falls. The facility’s Fall/Emergency Response Policy and Procedure (updated 07/15/24) revealed that staff is to avoid moving the resident, except to protect them from further injury. Then Management will complete an assessment and may allow resident to be assisted up to a chair if there’s no head trauma, no loss of consciousness, resident denies pain, has a full range of motion, and is alert. Interview with the Executive Director indicated that 911 is called for memory care residents and assisted living residents may accept or deny a 911 call. If the paramedics arrive, the power of attorney may authorize or deny paramedic transportation. The Executive Director stated that private paramedic vendors are not contacted, and no concerns have been expressed directly to the Executive Director. The Executive Director start date was 07/16/24. The Executive Director and Wellness Director indicated that: staff are not license and do not request special medical inventions from the paramedics, more staff have been added to help prevent resident falls, and most falls occur in the residents’ rooms. Interview with the Wellness Director indicated that more activities have been implemented for fall risk residents to provide more supervision.

Regarding the allegation “Conduct inimical," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

An exit interview was conducted and a copy of this report was provided to the Executive Director Brittany Kavanaugh.