Traditions Health

“Based on record review and interview, the agency failed to ensure all falls were documented in an occurrence log to be included in their Quality Assurance Performance Improvement program for 5 of 8 active records reviewed (Patients #1, #3, #4, #6, and #8) with falls not documented on the occurrence log. Findings Include: 1. An agency policy titled “ Occurrence/Violence Incident Reporting” reviewed 09/01/2024 indicated but was not limited to, “ … The Hospice will document and report all occurrences … that deviate from routine Hospice operations and may result in injury or potential harm to a patient or Hospice staff. … I. Adverse Events include, but are not limited to: A. Provision of care errors such as … falls …” 2. A review of Patient #1’s clinical record evidenced “Client Episode Coordination Notes Report” from 08/23/2025 through 11/13/2025. The coordination note dated 08/23/2025 at 9:36 PM by the on-call triage company, Entity 13, by Person 14, indicated Patient #1 had fallen out of their wheelchair and hit the right side of their face and were currently bleeding. The note evidenced RN 3 was aware of the patient’s fall and injury and an RN visit was scheduled. The coordination note dated 08/23/2025 at 11:49 PM by RN 3 revealed they had canceled the visit made at 9:36 PM on 08/23/2025 because the assisted living facility nurse had informed RN 3, Patient #1 had fallen asleep. Patient #1’s clinical record evidenced the next RN visit was made by RN 3 on 08/24/2025 at 9:06 AM. The nurse indicated in their narrative, the patient had a bruise on their upper lip on the right side. A review of the agency’s “QI (sic Quality Improvement) Event Summary” failed to evidence Patient #1’s fall on 08/23/2025. During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained when a fall occurs, an occurrence log would be completed. 3. A review of Patient #3’s clinical record evidenced “Client Episode Coordination Notes Report” from 09/16/2025 through 11/13/2025. The coordination note dated 09/16/2025 at 3:47 AM by the on-call triage company, Entity 13, by Person 15, they indicated in the note, Patient #3 had fallen while attempting to ambulate to the restroom and complained of pain in their hands, with no other injuries noted. The note evidenced the assisted living facility put an order in for an x-ray (a type of radiation used to see inside of the body) to be completed on the patient. Patient #3’s clinical record evidenced the patient was seen by RN 2 on 09/30/2025 at 2:17 PM. The narrative revealed the x-ray taken of the patient’s hands failed to reveal any injury. A review of the agency’s “QI Event Summary” failed to evidence Patient #3’s fall on 09/28/2025. During an interview with RN 2 on 11/14/2025 at 10:05 AM, they indicated they will then complete an incident report after a fall, which is separate from the communication notes. 4. A review of Patient #4’s clinical record evidenced a coordination note dated 09/03/2025 at 9:46 PM by Person 16, from the on-call triage agency, Entity 13. The note evidenced the triage line received a call from Patient #4’s assisted living facility at 8:57 PM on 09/03/2025 indicating the patient had an unwitnessed fall and hit their head. RN 2 was notified. Patient #4’s clinical record revealed RN 2 saw the patient on 09/03/2025 at 9:45 PM. A review of the agency’s “QI Event Summary” failed to evidence Patient #4’s fall on 09/03/2025. During an interview with RN 4 on 11/14/2025 at 3:09 PM, they explained after a fall, they were to complete an occurrence report even if it was an unwitnessed fall. 5. A review of Patient #6’s clinical record evidenced an RN visit note dated 09/04/2025 at 12:04 PM. The visit note evidenced a communication note indicating the patient had fell on 09/04/2025 and had hit their head. A review of the agency’s “QI Event Summary” failed to evidence Patient #4’s fall on 09/03/2025. During an interview with RN 1 on 11/14/2025 at 3:26 PM, they explained they will complete a client occurrence for any falls, will include what happened, how it was addressed, and determine what interventions needed to be changed. 6. A review of Patient #8’s clinical record evidenced coordination notes dated 08/14/2025 through 10/31/2025. Patient #8’s clinical record evidenced a coordination note dated 08/15/2025 at 10:30 PM by the on-call triage company, Entity 13, by Person 17, indicated the patient had fallen and had no injuries. The coordination note dated 08/25/2025 at 2:01 AM by Person 15, from the on-call triage agency, Entity 13 indicating Patient #8 had a new skin tear on their left arm and Emergency Medical Services had been called. The coordination note dated 08/25/2025 at 2:42 AM by Person 18, from the on-call triage agency, Entity 13, indicated Patient #8’s skin tear was no longer bleeding. The wound was treated by Emergency Medical Services and it was no longer bleeding. An RN visit note was conducted on 08/26/2025 at 6:15 PM by RN 4 to treat Patient #8’s new skin tear with the wound care orders. Patient #8’s coordination note dated 09/14/2025 at 2:52 PM, by Person 19, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. The note revealed RN 3 was notified. Patient #8’s coordination note dated 09/14/2025 at 8:35 PM, by Person 19, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. The note revealed RN 3 was notified. The coordination note dated 09/20/2025 at 2:37 AM, by Person 21, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. RN 3 was notified. An RN visit note was completed by RN 3 on 09/21/2025 at 8:34 AM for a follow-up visit for Patient #8’s fall. The coordination note dated 10/04/2025 at 2:44 PM by Person 22, with Entity 13, indicating Patient #8 had fallen with no visible injuries and RN 3 was notified. The coordination note dated 10/25/2025 at 10:56 PM by Person 23, with Entity 13, indicating Patient #8 had fallen and had no injuries. RN 3 was notified. A review of the agency’s “QI Event Summary” failed to evidence Patient #8’s falls on 08/15, 08/25, 09/14, 09/20, 10/04, and 10/25/2025. During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained when a fall occurs, an occurrence log would be completed. 7. During an interview with the Executive Director (Admin 1) and the Vice President of Quality (Admin 7) on 11/14/2025 at 3:45 PM, the Executive Director explained an occurrence report will be filed when a fall occurs.”

“Based on record review and interview, the agency failed to ensure all falls were documented in an occurrence log to be included in their Quality Assurance Performance Improvement program for 5 of 8 active records reviewed (Patients #1, #3, #4, #6, and #8) with falls not documented on the occurrence log. Findings Include: 1. An agency policy titled “ Occurrence/Violence Incident Reporting” reviewed 09/01/2024 indicated but was not limited to, “ … The Hospice will document and report all occurrences … that deviate from routine Hospice operations and may result in injury or potential harm to a patient or Hospice staff. … I. Adverse Events include, but are not limited to: A. Provision of care errors such as … falls …” 2. A review of Patient #1’s clinical record evidenced “Client Episode Coordination Notes Report” from 08/23/2025 through 11/13/2025. The coordination note dated 08/23/2025 at 9:36 PM by the on-call triage company, Entity 13, by Person 14, indicated Patient #1 had fallen out of their wheelchair and hit the right side of their face and were currently bleeding. The note evidenced RN 3 was aware of the patient’s fall and injury and an RN visit was scheduled. The coordination note dated 08/23/2025 at 11:49 PM by RN 3 revealed they had canceled the visit made at 9:36 PM on 08/23/2025 because the assisted living facility nurse had informed RN 3, Patient #1 had fallen asleep. Patient #1’s clinical record evidenced the next RN visit was made by RN 3 on 08/24/2025 at 9:06 AM. The nurse indicated in their narrative, the patient had a bruise on their upper lip on the right side. A review of the agency’s “QI (sic Quality Improvement) Event Summary” failed to evidence Patient #1’s fall on 08/23/2025. During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained when a fall occurs, an occurrence log would be completed. 3. A review of Patient #3’s clinical record evidenced “Client Episode Coordination Notes Report” from 09/16/2025 through 11/13/2025. The coordination note dated 09/16/2025 at 3:47 AM by the on-call triage company, Entity 13, by Person 15, they indicated in the note, Patient #3 had fallen while attempting to ambulate to the restroom and complained of pain in their hands, with no other injuries noted. The note evidenced the assisted living facility put an order in for an x-ray (a type of radiation used to see inside of the body) to be completed on the patient. Patient #3’s clinical record evidenced the patient was seen by RN 2 on 09/30/2025 at 2:17 PM. The narrative revealed the x-ray taken of the patient’s hands failed to reveal any injury. A review of the agency’s “QI Event Summary” failed to evidence Patient #3’s fall on 09/28/2025. During an interview with RN 2 on 11/14/2025 at 10:05 AM, they indicated they will then complete an incident report after a fall, which is separate from the communication notes. 4. A review of Patient #4’s clinical record evidenced a coordination note dated 09/03/2025 at 9:46 PM by Person 16, from the on-call triage agency, Entity 13. The note evidenced the triage line received a call from Patient #4’s assisted living facility at 8:57 PM on 09/03/2025 indicating the patient had an unwitnessed fall and hit their head. RN 2 was notified. Patient #4’s clinical record revealed RN 2 saw the patient on 09/03/2025 at 9:45 PM. A review of the agency’s “QI Event Summary” failed to evidence Patient #4’s fall on 09/03/2025. During an interview with RN 4 on 11/14/2025 at 3:09 PM, they explained after a fall, they were to complete an occurrence report even if it was an unwitnessed fall. 5. A review of Patient #6’s clinical record evidenced an RN visit note dated 09/04/2025 at 12:04 PM. The visit note evidenced a communication note indicating the patient had fell on 09/04/2025 and had hit their head. A review of the agency’s “QI Event Summary” failed to evidence Patient #4’s fall on 09/03/2025. During an interview with RN 1 on 11/14/2025 at 3:26 PM, they explained they will complete a client occurrence for any falls, will include what happened, how it was addressed, and determine what interventions needed to be changed. 6. A review of Patient #8’s clinical record evidenced coordination notes dated 08/14/2025 through 10/31/2025. Patient #8’s clinical record evidenced a coordination note dated 08/15/2025 at 10:30 PM by the on-call triage company, Entity 13, by Person 17, indicated the patient had fallen and had no injuries. The coordination note dated 08/25/2025 at 2:01 AM by Person 15, from the on-call triage agency, Entity 13 indicating Patient #8 had a new skin tear on their left arm and Emergency Medical Services had been called. The coordination note dated 08/25/2025 at 2:42 AM by Person 18, from the on-call triage agency, Entity 13, indicated Patient #8’s skin tear was no longer bleeding. The wound was treated by Emergency Medical Services and it was no longer bleeding. An RN visit note was conducted on 08/26/2025 at 6:15 PM by RN 4 to treat Patient #8’s new skin tear with the wound care orders. Patient #8’s coordination note dated 09/14/2025 at 2:52 PM, by Person 19, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. The note revealed RN 3 was notified. Patient #8’s coordination note dated 09/14/2025 at 8:35 PM, by Person 19, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. The note revealed RN 3 was notified. The coordination note dated 09/20/2025 at 2:37 AM, by Person 21, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. RN 3 was notified. An RN visit note was completed by RN 3 on 09/21/2025 at 8:34 AM for a follow-up visit for Patient #8’s fall. The coordination note dated 10/04/2025 at 2:44 PM by Person 22, with Entity 13, indicating Patient #8 had fallen with no visible injuries and RN 3 was notified. The coordination note dated 10/25/2025 at 10:56 PM by Person 23, with Entity 13, indicating Patient #8 had fallen and had no injuries. RN 3 was notified. A review of the agency’s “QI Event Summary” failed to evidence Patient #8’s falls on 08/15, 08/25, 09/14, 09/20, 10/04, and 10/25/2025. During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained when a fall occurs, an occurrence log would be completed. 7. During an interview with the Executive Director (Admin 1) and the Vice President of Quality (Admin 7) on 11/14/2025 at 3:45 PM, the Executive Director explained an occurrence report will be filed when a fall occurs.”

“Based on record review and interview, the agency failed to ensure all patients were seen in a timely manner after a fall for 3 of 3 active records reviewed (Patients #1, #3, and #8) and 1 of 1 inactive record reviewed (Patient #10) with patients who fell and were not seen in a timely manner. Findings Include: 1. An agency policy titled “On Call for Patient Care” with a reviewed date of 09/01/2024 indicated but was not limited to, “ … Nursing and physician services will be available 24 hours, seven days a week … II. The Hospice will develop protocols and procedures for: A. Timely return of the call and back-up contingencies …” 2. A review of the agency Admission packet evidenced on page 3 included but was not limited to, “ … CALL HOSPICE FIRST … We are able to help you 24 hours a day, seven days a week, including holidays … Call us if there are any issues or concerns including: … You experience a fall …”. On page 19 of the Admission packet included but was not limited to, “ … Your Rights and Responsibilities … 11. To 24 hour/7 day/week availability of nursing services by calling the office number. …” 3. A review of Patient #1’s clinical record evidenced “Client Episode Coordination Notes Report” from 08/23/2025 through 11/13/2025. The coordination note dated 08/23/2025 at 9:36 PM by the on-call triage company, Entity 13, by Person 14, indicated Patient #1 had fallen out of their wheelchair and hit the right side of their face and were currently bleeding. The note evidenced RN 3 was aware of the patient’s fall and injury and an RN visit was scheduled on 08/23/2025. The coordination note dated 08/23/2025 at 11:49 PM by RN 3 revealed they had canceled the visit made at 9:36 PM on 08/23/2025 because the assisted living facility nurse had informed RN 3, Patient #1 had fallen asleep. Patient #1’s clinical record evidenced the next RN visit was made by RN 3 on 08/24/2025 at 9:06 AM. The nurse indicated in their narrative, the patient had a bruise on their upper lip on the right side. The clinical record failed to evidence Patient #1 was seen in a timely manner after the report of a fall with injury. During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained they were the weekend and on-call nurse. RN 3 indicated the agency had a triage line with nurses and if anyone called the on-call line it would go through the triage company and then to the on-call nurse with the agency. RN 3 would then call the individual who called the on-call line, determine the problem, and inquire whether they would want RN 3 to come see the patient. RN 3 indicated they would go to see the patient as soon as possible. If the patient had a fall with no injury, they determined if the patient needed any assistance or if they had a visit later in the day. They clarified if a patient had an injury from a fall, they will go out immediately to assess the patient even if the facility the patient lived in had already addressed the injury or wound. When queried regarding Patient #1’s injury on 08/23/2025, which resulted in an injury. They explained they could not remember why they had not gone out immediately to see them. They confirmed they usually go out to see the patient within 24 hours after a fall without injury and an occurrence log would be completed. 4. A review of Patient #3’s clinical record evidenced “Client Episode Coordination Notes Report” from 09/16/2025 through 11/13/2025. A review of the coordination note dated 09/28/2025 at 3:47 AM by the on-call triage company, Entity 13, by Person 15. Person 15 indicated in the note, Patient #3 had fallen while attempting to ambulate to the restroom and complained of pain in their hands, with no other injuries noted. The note evidenced the assisted living facility put an order in for an x-ray (a type of radiation used to see inside of the body) to be completed on the patient. Patient #3’s clinical record evidenced the patient was seen by RN 2 on 09/30/2025 at 2:17 PM. The narrative revealed the x-ray taken of the patient’s hands failed to reveal any injury. The clinical record failed to evidence Patient #3 was seen in a timely manner after the report of a fall without injury. During an interview with RN 2 on 11/14/2025 at 10:05 AM, they indicated for the on-call process, the triage line will call them and would follow-up with the patient or the person who called. If a patient had a fall with an injury or change of condition they would immediately visit the patient. A fall with no injury will result in a visit the next day to complete a follow-up from the fall. They will then complete an incident report which is separate from the communication notes. 5. A review of Patient #8’s clinical record evidenced coordination notes dated 08/14/2025 through 10/31/2025. The coordination note dated 08/25/2025 at 2:01 AM by Person 15, from the on-call triage agency, Entity 13 indicating Patient #8 had a new skin tear on their left arm and Emergency Medical Services had been called. The coordination note dated 08/25/2025 at 2:42 AM by Person 18, from the on-call triage agency, Entity 13, indicated Patient #8’s skin tear was no longer bleeding. The wound was treated by Emergency Medical Services and it was no longer bleeding. A review of a RN visit note dated 08/26/2025 at 6:15 PM and signed by RN 4 to treat Patient #8’s new skin tear on their left arm with the new wound care orders by cleaning the wound with wound cleanser, dried with gauze, applied vaseline gauze, covered with gauze, and secured with wrap and tape. The coordination note dated 09/20/2025 at 2:37 AM, by Person 21, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. RN 3 was notified. An RN visit note was completed by RN 3 on 09/21/2025 at 8:34 AM for a follow-up visit for Patient #8’s fall. The clinical record failed to evidence Patient #3 was seen in a timely manner after the report of a fall with or without injury. During an interview with the Complainant on 11/12/2025 at 2:45 PM, they indicated patients’ encountering changes in condition and falls, the clinicians were not going out to see the patients within 24 hours. They explained how the as needed RN 4 will inform the complainant the visit was taken care of, but will look and find no visits for the day the visit was needed. They explained Patient #8’s Assisted Living Facility, Entity 2, had called the complainant and informed them the patient had fallen and sustained an injury on a Monday at 2:00 AM, and a clinician had not gone out to assess the patient. RN 4 will put in the notes, the patient had declined the services, but the patients were not being called or sending any clinicians out to assess the patients. The Complainant will message the Executive Director (Admin 1) and RN 4 through electronic mail informing them of injuries to patients, and they will not respond back to the Complainant informing them of the patient being seen by a clinician. During an interview with RN 4 on 11/14/2025 at 3:09 PM, they explained they helped cover visits when needed and will help with on-call. They indicated the agency’s on-call process was the call would go through the triage line, they would notify the nurse on-call if appropriate and relay the information from the caller. It all was dependent on the situation, if there was a fall with no injuries or no symptoms, they would follow-up with the patient within 24 hours or by the next day. A fall with injury included the normal procedure of going out to the patient immediately, and would only wait if the patient, family/caregiver, or facility declined them going out at the time. They explained, if the patient was resting after the injury, the facility or family/caregiver would tell the agency not to come see the patient. They had not heard of any issues with the patients not receiving their MSW or Aide visits. RN 4 said they were unable to remember why they had not gone out to see Patient #10 after their fall on 09/01/2025. After a fall, they were to complete an occurrence report even if it was an unwitnessed fall. 6. A review of the inactive clinical record for Patient #10 evidenced a coordination note dated 09/01/2025 at 10:20 PM by Person 24, from Entity 13. The note indicated the patient had fallen and had a small red bump on the right side of their head. The note revealed RN 4 was notified of the fall and injury. The inactive clinical record for Patient #10 evidenced a RN visit note dated 09/02/2025 at 10:52 AM by RN 1. The clinical record failed to evidence Patient #10 was seen in a timely manner after the report of a fall with injury. During an interview with RN 1 on 11/14/2025 at 3:26 PM, they explained the on-call process. The caller would call the on-call line and would be in contact with someone from the triage line. If a fall or change in condition is reported, they will go out to assess the patient as soon as possible if there is an injury. A fall with no injury would result in RN 1 asking the caller if they want the RN to make a visit, most of the time they decline, and they will do a follow-up visit for the fall the start of the next day. They will complete a client occurrence for any falls, will include what happened, how it was addressed, and determine what interventions needed to be changed. 7. During an interview with the Physician Designee (Other Staff 3) on 11/12/2025 at 2:03 PM, they indicated they were the acting Medical Director of the agency, while the Medical Director was not working at the agency. They explained how the Interdisciplinary group discussed any issues with the patients and any needs needing to be addressed. Other Staff 3 declared they were updated frequently on falls and infections. For falls, the clinicians were to assess the situation and determine why the patient fell and reevaluate to determine if any changes to care were needed. They indicated the patients had access to care 24 hours a day, seven days a week. If there is an issue or concern after hours, someone was available to address any issues after hours. 8. During an interview with Admin 1 and the Vice President of Quality (Admin 7) on 11/14/2025 at 3:45 PM, Admin 1 explained the on-call service included a triage nurse answering service, to determine what the needs were and whether a clinician visit was needed. If there was a fall with injury or a symptom needed to be managed, they should go to assess the patient immediately. At times, the facility will ask the clinician not to come because the patient was resting, they are to note the facility asking the clinician not to make a visit. If there is a fall with no injury, the clinician has 24 hours to go and assess the patient. An occurrence report will be filed when a fall occurs.”

“Based on record review and interview, the agency failed to ensure all patients were seen in a timely manner after a fall for 3 of 3 active records reviewed (Patients #1, #3, and #8) and 1 of 1 inactive record reviewed (Patient #10) with patients who fell and were not seen in a timely manner. Findings Include: 1. An agency policy titled “On Call for Patient Care” with a reviewed date of 09/01/2024 indicated but was not limited to, “ … Nursing and physician services will be available 24 hours, seven days a week … II. The Hospice will develop protocols and procedures for: A. Timely return of the call and back-up contingencies …” 2. A review of the agency Admission packet evidenced on page 3 included but was not limited to, “ … CALL HOSPICE FIRST … We are able to help you 24 hours a day, seven days a week, including holidays … Call us if there are any issues or concerns including: … You experience a fall …”. On page 19 of the Admission packet included but was not limited to, “ … Your Rights and Responsibilities … 11. To 24 hour/7 day/week availability of nursing services by calling the office number. …” 3. A review of Patient #1’s clinical record evidenced “Client Episode Coordination Notes Report” from 08/23/2025 through 11/13/2025. The coordination note dated 08/23/2025 at 9:36 PM by the on-call triage company, Entity 13, by Person 14, indicated Patient #1 had fallen out of their wheelchair and hit the right side of their face and were currently bleeding. The note evidenced RN 3 was aware of the patient’s fall and injury and an RN visit was scheduled on 08/23/2025. The coordination note dated 08/23/2025 at 11:49 PM by RN 3 revealed they had canceled the visit made at 9:36 PM on 08/23/2025 because the assisted living facility nurse had informed RN 3, Patient #1 had fallen asleep. Patient #1’s clinical record evidenced the next RN visit was made by RN 3 on 08/24/2025 at 9:06 AM. The nurse indicated in their narrative, the patient had a bruise on their upper lip on the right side. The clinical record failed to evidence Patient #1 was seen in a timely manner after the report of a fall with injury. During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained they were the weekend and on-call nurse. RN 3 indicated the agency had a triage line with nurses and if anyone called the on-call line it would go through the triage company and then to the on-call nurse with the agency. RN 3 would then call the individual who called the on-call line, determine the problem, and inquire whether they would want RN 3 to come see the patient. RN 3 indicated they would go to see the patient as soon as possible. If the patient had a fall with no injury, they determined if the patient needed any assistance or if they had a visit later in the day. They clarified if a patient had an injury from a fall, they will go out immediately to assess the patient even if the facility the patient lived in had already addressed the injury or wound. When queried regarding Patient #1’s injury on 08/23/2025, which resulted in an injury. They explained they could not remember why they had not gone out immediately to see them. They confirmed they usually go out to see the patient within 24 hours after a fall without injury and an occurrence log would be completed. 4. A review of Patient #3’s clinical record evidenced “Client Episode Coordination Notes Report” from 09/16/2025 through 11/13/2025. A review of the coordination note dated 09/28/2025 at 3:47 AM by the on-call triage company, Entity 13, by Person 15. Person 15 indicated in the note, Patient #3 had fallen while attempting to ambulate to the restroom and complained of pain in their hands, with no other injuries noted. The note evidenced the assisted living facility put an order in for an x-ray (a type of radiation used to see inside of the body) to be completed on the patient. Patient #3’s clinical record evidenced the patient was seen by RN 2 on 09/30/2025 at 2:17 PM. The narrative revealed the x-ray taken of the patient’s hands failed to reveal any injury. The clinical record failed to evidence Patient #3 was seen in a timely manner after the report of a fall without injury. During an interview with RN 2 on 11/14/2025 at 10:05 AM, they indicated for the on-call process, the triage line will call them and would follow-up with the patient or the person who called. If a patient had a fall with an injury or change of condition they would immediately visit the patient. A fall with no injury will result in a visit the next day to complete a follow-up from the fall. They will then complete an incident report which is separate from the communication notes. 5. A review of Patient #8’s clinical record evidenced coordination notes dated 08/14/2025 through 10/31/2025. The coordination note dated 08/25/2025 at 2:01 AM by Person 15, from the on-call triage agency, Entity 13 indicating Patient #8 had a new skin tear on their left arm and Emergency Medical Services had been called. The coordination note dated 08/25/2025 at 2:42 AM by Person 18, from the on-call triage agency, Entity 13, indicated Patient #8’s skin tear was no longer bleeding. The wound was treated by Emergency Medical Services and it was no longer bleeding. A review of a RN visit note dated 08/26/2025 at 6:15 PM and signed by RN 4 to treat Patient #8’s new skin tear on their left arm with the new wound care orders by cleaning the wound with wound cleanser, dried with gauze, applied vaseline gauze, covered with gauze, and secured with wrap and tape. The coordination note dated 09/20/2025 at 2:37 AM, by Person 21, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. RN 3 was notified. An RN visit note was completed by RN 3 on 09/21/2025 at 8:34 AM for a follow-up visit for Patient #8’s fall. The clinical record failed to evidence Patient #3 was seen in a timely manner after the report of a fall with or without injury. During an interview with the Complainant on 11/12/2025 at 2:45 PM, they indicated patients’ encountering changes in condition and falls, the clinicians were not going out to see the patients within 24 hours. They explained how the as needed RN 4 will inform the complainant the visit was taken care of, but will look and find no visits for the day the visit was needed. They explained Patient #8’s Assisted Living Facility, Entity 2, had called the complainant and informed them the patient had fallen and sustained an injury on a Monday at 2:00 AM, and a clinician had not gone out to assess the patient. RN 4 will put in the notes, the patient had declined the services, but the patients were not being called or sending any clinicians out to assess the patients. The Complainant will message the Executive Director (Admin 1) and RN 4 through electronic mail informing them of injuries to patients, and they will not respond back to the Complainant informing them of the patient being seen by a clinician. During an interview with RN 4 on 11/14/2025 at 3:09 PM, they explained they helped cover visits when needed and will help with on-call. They indicated the agency’s on-call process was the call would go through the triage line, they would notify the nurse on-call if appropriate and relay the information from the caller. It all was dependent on the situation, if there was a fall with no injuries or no symptoms, they would follow-up with the patient within 24 hours or by the next day. A fall with injury included the normal procedure of going out to the patient immediately, and would only wait if the patient, family/caregiver, or facility declined them going out at the time. They explained, if the patient was resting after the injury, the facility or family/caregiver would tell the agency not to come see the patient. They had not heard of any issues with the patients not receiving their MSW or Aide visits. RN 4 said they were unable to remember why they had not gone out to see Patient #10 after their fall on 09/01/2025. After a fall, they were to complete an occurrence report even if it was an unwitnessed fall. 6. A review of the inactive clinical record for Patient #10 evidenced a coordination note dated 09/01/2025 at 10:20 PM by Person 24, from Entity 13. The note indicated the patient had fallen and had a small red bump on the right side of their head. The note revealed RN 4 was notified of the fall and injury. The inactive clinical record for Patient #10 evidenced a RN visit note dated 09/02/2025 at 10:52 AM by RN 1. The clinical record failed to evidence Patient #10 was seen in a timely manner after the report of a fall with injury. During an interview with RN 1 on 11/14/2025 at 3:26 PM, they explained the on-call process. The caller would call the on-call line and would be in contact with someone from the triage line. If a fall or change in condition is reported, they will go out to assess the patient as soon as possible if there is an injury. A fall with no injury would result in RN 1 asking the caller if they want the RN to make a visit, most of the time they decline, and they will do a follow-up visit for the fall the start of the next day. They will complete a client occurrence for any falls, will include what happened, how it was addressed, and determine what interventions needed to be changed. 7. During an interview with the Physician Designee (Other Staff 3) on 11/12/2025 at 2:03 PM, they indicated they were the acting Medical Director of the agency, while the Medical Director was not working at the agency. They explained how the Interdisciplinary group discussed any issues with the patients and any needs needing to be addressed. Other Staff 3 declared they were updated frequently on falls and infections. For falls, the clinicians were to assess the situation and determine why the patient fell and reevaluate to determine if any changes to care were needed. They indicated the patients had access to care 24 hours a day, seven days a week. If there is an issue or concern after hours, someone was available to address any issues after hours. 8. During an interview with Admin 1 and the Vice President of Quality (Admin 7) on 11/14/2025 at 3:45 PM, Admin 1 explained the on-call service included a triage nurse answering service, to determine what the needs were and whether a clinician visit was needed. If there was a fall with injury or a symptom needed to be managed, they should go to assess the patient immediately. At times, the facility will ask the clinician not to come because the patient was resting, they are to note the facility asking the clinician not to make a visit. If there is a fall with no injury, the clinician has 24 hours to go and assess the patient. An occurrence report will be filed when a fall occurs.”