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32 | [Cont. from LIC 9099]
Regarding the allegation, R1 had an unwitnessed fall in the bathroom on 05/05/2026, and was sent out for evaluation and treatment due to pain in their right leg. R1 was diagnosed with a right hip fracture at the hospital. Interviews revealed that R1 had been experiencing a noticeable decline beginning in mid-April 2026. Staff consistently reported that R1 required increased assistance with activities of daily living, including grooming, dressing, bathing, reminders for meals, and escorts due to fall-risk concerns. Interviews indicated that R1 demonstrated at times some confusion, periods of disorientation, and resistance to accepting assistance due to a desire to remain independent. Staff stated that R1 rarely used the call pendant, despite frequent reminders about using the device, and preferred to perform most tasks independently.
Interviews further revealed that, in response to R1’s decline, R1's care plan was updated through a change of condition assessment. Staff reported performing more frequent safety checks, two to three times per shift or more due to R1's decline. Staff stated that these checks were conducted to monitor R1’s safety, ensure R1 was getting to meals, and prevent falls. Staff stated they routinely checked on R1 in the mornings, during meal periods, and throughout their shifts due to concerns about R1's decreased awareness and occasional confusion or forgetfulness.
Records review corroborated staff statements. A change of condition assessment dated April 2026 documented that R1 required increased assistance with ADLs, including medication assistance, standby help for grooming and toileting, and hands-on assistance for bathing, and notes that R1 was at moderate risk for falling according to the fall risk assessment and was to be provided personalized interventions, per fall management protocol. R1 did not require status checks.
Records review of R1's incident report dated 05/05/2026 documented that R1 sustained an unwitnessed fall in the bathroom, was unable to bear weight, and was transported to the hospital where a right hip fracture was diagnosed. Review of charting notes reflected that staff discovered the fall during routine medication pass and took appropriate steps, including contacting emergency services and completing all required notifications.
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 Executive Director Shawn Amirhoushmand 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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