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32 | The facility notified residents responsible party for both R1 and R2. Both residents were placed on 72-hour alert charting for post altercation observation. The facility notified both residents’ hospice agency’s to see if there was a change in condition. LPA Lund reviewed the 72-hour charting for both residents. The facility staff couldn’t have predicted R1 having an episode in the community day room.
Based on facility records reviewed and interviews with staff, on the information provided, it was unclear if staff did not prevent resident from harming another resident in care, therefore the allegation was deemed UNSUBSTANTIATED.
Staff did not provide adequate supervision to resident in care resulting in falls- Based on records reviewed, interviews with staff, and residents in care. Resident (R1) moved into the facility on 08/25/2022 and moved out on 10/05/2024. LPA Lund reviewed Unusual Incident/Injury Reports dated 02/06/2024 & 6/17/2024. On 1/31/2024 R1 was observed on the floor near R1’s room. R1 had a large skin tear to the left of resident’s forehead. R1 was awake and responding but unable to verbalize what happened. 911 was called immediately, staff held pressure to the injury until EMT’s arrived. R1 was transported to Doctor’s Medal Hospital and treated in the Emergency Room. R1 returned to the facility on the same day. On 1/31/2024 Global Hospice visited R1 and there was no significant change in status. On 6/13/2024 had a large skin tear to the left of resident’s forehead. R1 had a large bump on the left side and laceration present well. R1 was awake and responding appropriately. R1 didn’t know how the injury happened. 911 was called and EMT’s took R1 to Doctors Medical Center. R1 returned to the facility on the same day. On 6/13/2024 Global Hospice visited R1 and there was no significant change in status. LPA Lund reviewed facility staffing schedules from 1/1/2024 through 1/31/2024 and 6/1/2024 through 6/30/2024 and there is no staff ratio for RCFE’s but is consistent with residents in care.
Based on records reviewed, interviews with staff, and residents in care, on the information provided, it was unclear if staff did not provide adequate supervision to resident in care resulting in falls, therefore the allegation was deemed UNSUBSTANTIATED.
As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.
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