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32 | In regards to the allegation that "Client sustained an injury while in care due to inadequate supervision provided by facility staff," it is alleged that C1 had a fall in their room on 6/17/2024 which caused C1 to sustain a black eye, and that C1 called for staff assistance however they did not assist C1. Therefore C1's roommate had to assist C1 from their fall, and the black eye C1 sustained was not noticed until their day program staff noticed the injury the following day. During interviews with the clients, none of them corroborated the allegation that staff neglect caused an injury to C1 or anyone else in the home. During an interview with C1, they stated that during the incident they were sitting on the bed and fell in their room, and that soon after their roommate helped C1 up from the floor and assisted them with getting back into bed. C1 stated that whenever they ask staff for any kind of assistance, they are always able to assist C1. During interviews with the staff, none of them corroborated that they did not adequately supervise C1 which led to their injury. One of the staff interviewed stated that staff were not aware that C1 fell because C1 did not notify that they fell during the early morning hours of 6/17/2024, and the black eye had not set into C1's face by the time they left for day program and therefore were unaware of the incident until they were notified of it by the day program. Another staff interviewed stated that they now make sure to conduct thirty (30) minute checks on C1 at night to ensure that they respond appropriately to any potential future falls. During record LPA observed that the facility submitted an SIR of the event in accordance with required reporting requirements. During record review of C1's IPP prior to the incident, it was mentioned that C1 was to be monitored for falls particularly on stairs and uneven surfaces along with showers. After the incident an update to the IPP was made to include that C1 will be assisted by staff on all transfers from their wheelchair, that C1 will be be monitored closely due to high risk of falls, and that C1 will notify staff immediately of any falls in the future so that the facility can seek prompt medical care if necessary.
Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview held, and a copy of this report was provided. |