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32 | R1 was using their walker to walk over to the dining room for dinner with their daughter when they fell back and hit their head. Charting Notes do not indicate if R1’s pendant was pressed at that time or how staff was alerted of R1’s fall.
Interviews were conducted with one witness, two staff, and six residents. During their interview, R1’s daughter, Witness 1 (W1) stated that on October 16, 2025 at 4:00 a.m., R1 called them crying and stated they had pressed the call button in their bathroom due to having fallen and had waited for staff to arrive. Per W1, R1 informed them they got back in bed because no one came and had fallen asleep. W1 stated R1 woke up again because their head was hurting. Per W1, they told R1 to call 911 and stated it was R1 who had called 911 “as far as” they knew. W1 stated they then called the front desk to inform them of R1’s fall and questioned why staff had not gone to check on R1. W1 stated staff apologized and stated they thought it was a “false alarm” because R1 had never pressed their call button before. W1, however, was unable to identify staff alleged to have stated they thought it was a “false alarm.” Per W1, on October 19, 2025, they had been present at the time of R1’s fall and had pressed R1’s pendant, but no one came, so they pressed it again and no one came until they called the front desk and were subsequently informed staff were tending to another resident emergency, and paramedics were already on-site. R1 is no longer a resident at the facility. Three separate attempts were made to reach R1 by phone, however, R1 could not be reached to confirm or deny allegation. During their interview, S1 stated that on October 16, 2025 at approximately 4:00 a.m., they received a call from W1 notifying them that R1 had an unwitnessed fall in their bedroom and had been pressing their call button. S1 stated they did not know how long it had been since R1’s fall or how many times R1 had pressed their call button. Per S1, if a resident keeps pressing their pendant and staff go to clear another resident’s call, the call system will inevitably clear their call as well. S1 stated that upon responding to R1’s room they found R1 sitting on the edge of their bed. Per S1, R1 informed them they had gotten up to go use the restroom and had fallen and hit their head on the television stand and that is when paramedics were called. S1 stated they could not recall ever personally telling W1 they had not checked on R1 due to R1 never pressing their pendent nor did they recall any other staff making that statement. S1 stated they had called the paramedics as soon as R1 informed them that they had hit their head and paramedics arrived between “five to six minutes” later. During their interview, S2 stated on October 19, 2025, R1 was walking with their walker with the assistance of W1, when they fell back and hit their head. Per S2, W1 reported pressing R1’s pendant, however, S2 was tending to another resident emergency at the time and stated they were unsure how long it had taken for them to respond but estimated "it could have been ten to fifteen minutes." (Cont. LIC9099-C) |