Staff informed that the incident occurred when the caregiver involved, Staff 1 (S1), was assisting R1 with an Activity of Daily Living (ADL). Interviews revealed that S1 followed the 1-person assist procedures by ensuring that R1's walker was in front of them prior to the assist with both hands positioned on the walker. Interviews further revealed that R1's legs buckled under them during the ADL, causing them to start falling forward. S1 was able to catch R1 on their left side, preventing them from falling to the ground. Additionally, staff interviews revealed that the incident was elevated internally, documented, and timely notifications were made to the Department, Hospice, and R1’s Responsible Party. Management staff informed that after the incident R1's care plan was updated to require 2-person ADL assistance. While interviews confirmed that R1 suffered bruising from the incident, the injury was not a result of neglectful treatment, but of staff properly following ADL procedures, which prevented R1 from falling to the ground and suffering greater injury. Interviews further revealed that R1 was prescribed blood thinners, which caused them to easily bruise. Staff interviews did not show that staff were neglectful in R1's care, or that lack of care resulted in R1's bodily injury.

Records review revealed that the Licensee submitted an Unusual Incident/Injury Report to the Department on 2/24/23, within the required timeframe. The Incident Report was consistent with staff statements regarding the event and showed that the Licensee contacted the hospice agency and R1's family regarding the bruises. Written communication between the hospice agency and the facility showed that R1's bruising was being monitored after the incident. Hospice x-ray records dated 2/22/23 showed no fracture had occurred from the incident. Internal facility documentation revealed written, consistent, staff accounts of the incident. Hospice and facility records showed that R1 was prescribed blood thinners, which were placed on hold after the incident due to the bruise spreading.

Three (3) outside sources were interviewed during the investigation, including R1's Responsible Party and the hospice agency involved in R1's care. Outside sources revealed that the facility elevated the incident after the bruises from the incident began to develop. Outside sources revealed that staff informed the family of the bruising the morning of the incident, and that a care conference was held between the facility, R1's family, and Hospice the next day, where the family declined to have R1 sent out to the hospital. Outside source statements confirmed that x-rays were taken on 2/22/23, revealing no fractures.

Regarding the allegation, “Staff did not seek medical attention for resident”, it was alleged that facility staff did not call for emergency medical care after R1’s incident. Staff interviews revealed that R1's bruise did not immediately present after the incident but developed throughout the day. Staff interviews revealed that S1 caught R1 during the incident and R1 did not show indication that they were in pain or injured. Staff interviews further revealed that the hospice agency and the family were notified the morning of incident when the bruising was observed by R1’s shower aide; the hospice agency assessed R1 on 2/17/23. Staff interviews additionally revealed that staff were in continuous communication with the hospice agency and the family days after the incident, including a care conference where the family declined to have R1 sent out to the hospital. Staff consistently stated that mobile x-rays were requested by the facility and arranged by the hospice agency; the x-rays were taken on 2/22/23 and confirmed that R1 did not suffer a fracture from the incident.

Review of facility records corroborated staff statements, revealing that the family and facility requested x-rays for R1, and the hospice agency arranged for x-rays to be taken on 2/22/23. The x-rays showed that R1 did not suffer fractures from the incident. Facility records showed that staff remained in communication with the hospice agency and assisted with monitoring R1 days after the incident. Additionally, facility records showed that R1's care plan was updated after the fall, upgrading them from a 1-person assist to 2-person assist for transfers and ADLs. Hospice records dated 2/3/23 showed that the facility had a fall mat, hi/low hospital bed, wheelchair, and over the bed table in place for R1 due to their medical condition. Outside source and facility records showed that based on the timeline of events, the hospice agency and family were informed of the incident and subsequent bruising within approximately two (2) hours of the event occurring. Records showed that facility staff followed the protocol for residents on hospice by notifying the hospice agency and following the instruction given.

Outside source interviews corroborated staff statements that the family declined for R1 to be sent out to the hospital following the incident. Outside source interviews also corroborated staff interviews and records, which evidenced that R1 received x-rays on 2/22/23 with no finding of a fracture.

Resident interview- Interview was attempted with R1, however R1 did not respond to any of the questions asked. Records and interviews showed that R1 was non-verbal and unable to communicate with words.

(Continued on LIC9099-C p.4)

Regarding the allegation, “Licensee did not report resident's change in condition to Responsible Party”, it was alleged that R1’s Responsible Party was not notified of the near-falling incident with subsequent bruising. Staff interviews further revealed that the incident occurred between 6:30am to 7:30am, when S1 was assisting R1 before breakfast; during this time bruises had not developed and R1 did not show signs of injury or pain. Staff interviews further revealed that at approximately 9:30am R1’s shower aide arrived to the facility, observed bruises developing under R1’s arm, and notified S1 who elevated the incident to the Medical Technician (Med Tech), S2. S2 then notified the hospice agency. During this time R1’s family member arrived to the facility and was informed of the incident and bruising by S2. This family member took photos of R1’s bruises at 10:46am and sent them to R1’s Responsible Party. Staff interviews revealed that the family was in communication with the facility the day of the incident and the family declined to have R1 sent out to the hospital during a care conference on 2/17/23. Staff interviews showed that the timeframe between the incident occurring and R1’s family member arriving to the facility was approximately two (2) hours.

Outside source interviews were inconsistent regarding the timeline of family notifications and from whom the requests for medical interventions/assessments were made. Outside source interviews revealed contradictory statements regarding when or if the Responsible Party was notified and if the family decision not to send R1 to the hospital was made directly by the Responsible Party or through the visiting family member. Outside source interviews revealed that R1’s visiting family member first notified R1’s Responsible Party of the bruising because the family member was at the facility as the staff were discovering that bruises had developed. Outside sources informed that the visiting family member arrived at the facility the day of the incident at approximately 9:30am and was immediately informed by S2 of the bruising. This family member took photos and sent them to R1’s Responsible Party at 10:46am, confirmed by photograph timestamps. Outside interviews revealed that R1's Responsible Party was making decisions through the visiting family member, and that a care conference was held between the family and facility the day after the incident.

Review of facility charting notes dated 2/16/23 showed that R1's family was present at the facility during the PM shift the day of the fall. The facility submitted Unusual Incident/Injury Reports to the Department dated 6/21/23 and 6/24/23; the reports stated that S2 notified the hospice agency and R1's Responsible Party and that the family requested additional x-rays to chest and ribs for R1. (Continued on LIC9099-C p.5)

Resident interview- Interview was attempted with R1, however R1 did not respond to any of the questions asked. Records showed that R1 was non-verbal and unable to communicate with words.

While the evidence found does not clearly show when R1’s Responsible Party was directly made aware of the incident by the Licensee, the evidence confirms that R1’s Responsible Party was making decisions the day of the incident, was present at the facility the day of the incident, and was involved in the care conference the day after the incident. The evidence also showed that the facility honored the Responsible Party’s decisions regarding R1’s care directly after the incident. The evidence does not show that the facility significantly or intentionally delayed notification to R1’s Responsible Party regarding the incident.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Marketing Manager Maria Flores, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.