Residential Care Services Investigation Summary Report

Provider/Facility: BROWNS POINT ADULT FAMILY HOME(687439)

Intake ID(s): 3302962, 3302974

License/Cert. #: AF661000Investigator: Cramer, Lisa Region/Unit: RCS Region 3/Unit A Investigation

Date(s):12/16/201612/20/2016

through

Complainant Contact Date(s): 12/16/2016, 12/19/2016, 12/20/2016Allegations:Amended 01/03/2017 due to Conclusion/Action reflecting "Failed facility practice not identified/No citation written" when theopposite was accurate. Failed Facility practice was identified and citations were written.

On 12/14/16, a resident representative arrived and noticed that had two black eyes and was in pain. The AFH providerexplained that the alleged victim (AV) had fallen the night before at approximately 8:00pm.

No family member had been contacted and no medical services were called. AV was admitted with a

Investigation Methods:Sample: 4 current residents, 1

discharged residentSample included the AV

Observations: General environmentStaff to residentinteractionsSuperficial examinationof resident skin

Interviews: 1 current resident1 resident representativein the homeStaffAFH provider

Record Reviews: Assessment and careplanIncident logP and p on reportingmedical emergenciesMedication log

Page 1 of 2

Residential Care Services Investigation Summary Report

Allegation Summary:On an unannounced visit to the AFH, the home was observed as clean and uncluttered. 4 residents, 2 caregiver staff and theAFH provider were at home; and 1 resident representative was visiting in the home. Residents were clean and groomed. Asuperficial observation of resident skin did not disclose any skin issues.Interview of 1 resident and 1 resident representative, did not disclose any care and services issues.Record review and AFH provider interview revealed there was 1 recently discharged resident from the home. The AFH providersaid she witnessed the resident falling on 12/13. The resident's nose bled, but the bleeding stopped. The resident said she wasOK and continued to watch TV. The AFH provider said she did not call emergency services to evaluate the resident and did notnotify the resident's representative (RR), doctor or state case manager. She said she knew the RR was coming the next day totake the resident to the dentist. A telephone interview of the RR disclosed the AFH did not notify the RR of the AV's injury. Sherecalled both of the AV's eyes were blackened, and when she asked the AV she said she hurt The RR said she took the AV to ahospital. A review of hospital records revealed the AV was diagnosed .Records indicated the AV was not discharged, when the RR said she did not want the AV to return to the AFH and RR was not ina situation to take the AV to her home.

Unalleged Violation(s): Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

WAC 388-76- 10225- Reporting requirement. Based on interview and record review, the AFH failed to ensure the AV'srepresentative, health care provider and State case manager received timely notification of the resident's witnessed fall at theAFH. This failure caused a delay in the resident receiving medical attention.WAC 388-76- 10400- Based on interview and record review, the AFH failed to ensure the AV received care to reach the highestlevel of physical well-being, when after a fall at the AFH where the AV was bleeding from her nose, the AFH did not seek medicalattention for Resident #5 in a timely way. This placed the resident at risk for physical and cognitive complications.WAC 388-76-10250-Based on interviews and record reviews, the AFH provider failed to follow the AFH's emergency responsepolicy and procedure which required staff to immediately contact emergency medical services (EMS) when former Resident #5fell and had a nose bleed. This failure caused a delay for Resident #5 to receive medical care.

Page 2 of 2