Statements from staff who assisted R1 corroborate that R1 was found partially under the bed when found during safety checks. Further, medical records reveal no injuries indicative of a bed falling and landing on R1’s neck. Staff interviewed reported that safety checks are done four times a shift unless residents are noted for 2 hour checks. While R1’s records indicated needing assistance in transferring to and from bed, records did not indicate R1 needing additional checking throughout the night. Staff interviews corroborated the information The Department received from the facility documented on an Unusual Incident/Injury Report. Per the report and staff interviews, facility staff followed appropriate protocol once aware of R1’s fall.

The Department has investigated the allegation of neglect/lack of supervision resulting in bed falling on resident and landing on resident’s neck. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate that R1’s fall and resulting injury was a result of neglect/lack of supervision, therefore this allegation is deemed unsubstantiated.

An exit interview was conducted with Cathy Allen, Executive Director, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.