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32 | Investigator Zertuche conducted interviews on 04/02/2024, from approximately 3:00pm to 4:00pm, with R1’s resident representatives; on 05/23/2024, from approximately 9:30am to 11:00am, with administrator and staff; on 06/04/2024, at approximately 3:30pm, with R1’s conservator; on 06/07/2024, at approximately 11:00am, with Community Memorial Hospital (CMH) nursing case manager; and on 06/10/2024, at approximately 8:30am, with the home health nurse. In addition, the investigator reviewed CMH medical records, A Plus Home Health Services records, and facility file documents related to R1.
A review of the facility documents for R1 revealed their physician’s report dated 03/07/2020 showed R1 was ambulatory with a diagnosis of memory loss, but able to perform most activities of daily living on their own. An incident report showed R1 was sent to the hospital on 02/13/2024 due to weakness and unresponsiveness. The following day, R1’s resident representative contacted the facility informing them R1 was diagnosed with a fractured femur. The facility conducted an internal investigation which revealed no reported incidents at the facility. There were several visits conducted by the home health agency prior to the incident but nothing of concern was noted. The facility notes and records indicated R1 sustained a previous injury in March 2023 where an unwitnessed fall was documented sustaining a broken arm. There were also notes of follow up visits to the doctor showing the injury had healed.
Information reported by the administrator revealed that on 02/13/2024, R1 was not looking well, and the administrator decided to send R1 to the hospital and contacted R1’s resident representative. The following day, R1’s resident representative contacted the facility stating R1 had a fractured femur. The administrator questioned the staff and reviewed video, but there was no reported fall. The administrator denied hitting or pushing R1 and has not witnessed or heard of any of the staff members or residents hit or push R1. The administrator was surprised to hear of the fracture since R1 was able to walk without pain. Staff confirmed R1 did not walk well, as R1 shuffled their feet, but was able to get around on their own. R1 also used a wheelchair for safety. In addition, R1 was constantly supervised by staff members as R1 required assistance for most activities of daily living. R1’s room was placed near the entrance by the front office where there is lots of traffic. However, R1 was always in the activity room with the other residents and staff members. Staff denied witnessing R1 fall or be mistreated. There are cameras in the facility, but they do not record beyond 30 days, so there was no footage available for the Department to review.
Continued on 9099-C |