Resident sustained a fracture while in care due to lack of care/supervision. – UNSUBSTANTIATED

It was alleged that a resident was left unsupervised and sustained a fall with injury as a result.

LPA reviewed an incident report dated 02/03/24 in which it was reported that at 1:00 PM Resident 1 (R1) had a witnessed fall in the dining room resulting in a left hip fracture. Resident stood up from the dining table and was starting to walk with her walker when she lost her balance and fell backwards. Staff was unable to get to R1 in time to assist with her fall. R1 is independent with transfers and mobility with her four wheeled walker. Resident did hit her head on the wall after she fell and did not lose consciousness. Resident was able to get up from the floor with assistance and take small, short steps. Resident's pain had increased shortly after and was then sent to the ER for evaluation. Resident was taken to ER via ambulance. Persons contacted: Monica Gralian PA-PCP, Jack- son, Nicole Braswell LVN- Administrator, Nancy Martinez- Wellness Director.

During staff interviews 3 of 3 staff stated the fall occurred in the dining room and was witnessed by staff. 3 of 3 staff stated R1 lost her balance holding her walker.

Memory care director stated R1 appeared to have gotten up from the table and she fell back. Staff saw it and tried to run to help her but didn’t make it in time.

Administrator stated It was a witnessed fall. R1 was getting up from the table to leave the room and a caregiver was there but was escorting another resident. The caregiver heard R1 call out and she turned around but was not able to get to R1. Staff contacted the administrator when R1 initially fell, she said she was not in pain. Administrator asked staff to call the family and ask what they would like. About an hour went by and the administrator didn’t hear anything. The med tech told the administrator that R1 had increased pain, so they called EMS. The family had called back and said, “No don’t send her out.” The med tech told the family that they were making the decision to send her out.

It was determined that the resident was in the dining room with staff present when they fell, the fall was witnessed by staff. The resident was not left unsupervised. The facility followed their protocol of notification. The allegation is unsubstantiated.

Continued on LIC9099-C

It was alleged that residents are wandering around half dressed.

3 of 3 staff stated they help the residents get dressed, a lot of them don’t understand how to get dressed themselves, if a resident takes off clothes they are re-directed.

Memory care director stated Every morning they (staff) assist them. Some residents prefer to be in pjs all day, but we try to dress them as appropriately as possible.

Administrator stated Most of them require get up assistance and staff go in and make sure they have appropriate clothes on. Some will wander out of their room with no pants, so we usher them back and help them get dressed.

It was determined that staff assist residents in getting dressed and if a resident attempts to disrobe in the common area they are re-directed. This allegation is unsubstantiated.

Staff are locking the residents in their bedrooms. – UNSUBSTANTIATED

It was alleged that residents are being put in their rooms and the door being shut and locked behind them.

Staff interviews revealed resident rooms are locked to keep other residents from going into other resident’s rooms. You have to use a key from the outside to unlock the doors but as soon as you turn the handle from the inside the doors open.

Memory care director stated There are a few that were requested by families because they didn’t like other residents going into their rooms but that is not the norm. The doors lock from the inside and a resident can leave the room without unlocking the door.

Administrator stated The doors can lock, we do have a couple of residents that they lock just from the outside and not the inside because they have aggressive behaviors. They can open the doors from the inside if the door is locked from the outside.

It was determined that resident rooms have locks on them to deter other residents from entering rooms that are not theirs. All resident room doors can be opened by the residents from the inside without having to unlock the door. This allegation is unsubstantiated.

Continued on LIC9099-C

Staff do not ensure a resident is being properly fed while in care. – UNSUBSTANTIATED

It was alleged that residents are left in bed and do not get to eat dinner.

3 of 3 staff interviewed stated if a resident doesn’t want to come to the dining room, they bring them a tray to their room. 3 of 3 staff stated that snacks are available to the residents.

Memory care director stated We take them a tray and go back and check to make sure it has not gotten cold. If it’s someone that needs eyes on while eating the staff will stay there with them. We do snack at and any time in between if they are hungry, we will give them something.

Administrator stated If they chose to stay in bed, we will bring a tray in their room and go back around and check to make sure they are eating while they are in their room.

It was determined that if a resident chooses to stay in bed staff bring them a meal tray, snacks are offered and available to residents. The allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to administrator Nicole Braswell.