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32 | [Cont. on LIC 9099]
Regarding the allegation, R1 was sent to the hospital upon the request of their responsible party, and was found to have a displaced femoral fracture. Interviews revealed that since R1 was admitted to the facility, R1 frequently cried, expressed distress, and exhibited facial grimacing as part of their baseline behavior, making it difficult for staff to distinguish baseline emotional behaviors from potential pain. Interviews stated anytime staff asked R1 if they were experiencing any pain or if the behavior was anxiety-related, R1 would respond that they were anxious. Multiple staff stated that R1 did not report any fall, and no fall was witnessed in the days prior to hospitalization and the day of hospitalization. Staff reported that R1 ambulated with both wheelchair and walker depending on preference, and that R1 had no visible injuries or complaints of hip pain prior to the incident. Interviews consistently stated that camera footage was reviewed and showed no fall or incident in monitored areas. Staff stated that R1 spent time in common areas and was monitored regularly.
Staff interviews revealed that when R1 exhibited baseline behavior on the day of hospitalization, emergency services were called at the request of the responsible party. Staff confirmed that R1 had previously been hospitalized from an unrelated health matter days earlier and had continued showing facial expressions that were described as consistent with their baseline. No staff reported observing a fall or any event that could clearly or consistently be associated with a new injury.
Records review revealed that R1’s service plan and medical records documented dementia, anxiety, muscle weakness, and a prior displaced femur fracture before admission to the facility. Records also documented that R1 required assistance with all ADLs and used both a wheelchair and walker. Records review of the incident report on 05/03/2026 revealed that R1’s responsible party observed R1 to be expressing pain and requested emergency services, and R1 was transported to the hospital and admitted with a displaced right femoral fracture.
Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Administrator Susan Caccam and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.
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