Deficiency #1
Rule/Regulation Violated:
A.R.S. § 36-420.B.2. Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls; definition<br> B. Each health care institution:<br> 2. Shall provide appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who is in distress and to a noninjured resident who has fallen, appears to be uninjured and is unable to reasonably recover independently. The first aid shall be in accordance with the resident's advance directives, if known. Staff who are certified in first aid shall be available at all times.
Evidence/Findings:
<p>Based on documentation review and interviews, the manager failed to ensure that personnel provided appropriate first aid in accordance with its certification training for first aid before the arrival of emergency medical services to a resident who is in distress and to a non-injured resident who has fallen as required under Arizona Revised Statutes (A.R.S.) 36-420.B.1-3.</p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of Department documentation revealed an intake report dated May 24, 2025 which included sworn testimony which stated, "Staff/facility insufficient to meet patient need for safety and wellbeing. Staff failed to recover [R1] per ARS 36-420. Inappropriate utilization of 911 system. On Scene Narrative (Author): LT 12 call to MorningStar assisted living facility for fall injury. LT 12 found [R1] lying prone face first on the ground in room on floor. LT 12 inquired if they just needed help picking the patient up. Three staff members on scene state that patient is on blood thinners and it is their policy to not pick the patient up. Staff member stated that they called a nurse that works for the facility named [E5] and [E5] said to leave [R1] and call 911 for eval. [R1] has no complaints for LT 12. [R1] does not stand on [R1's] own and uses a wheelchair. [R1] states all [R1] needs is to be picked up. Staff did not attempt to even roll patient over onto to back. LT 12 assisted patient into chair and patient had no complaints. Patient just wants to be put into bed. Patient audibly refused transport for LT 12. Issue tracker is for staff and assisted living facility leaving patient lying face first floor with no assistance."</p><p><br></p><p>2. In an interview, E1 acknowledged that first aid had not been provided <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">before the arrival of emergency medical services for a </span>noninjured resident who had fallen, appeared to be uninjured and was unable to reasonably recover independently.</p><p><br></p>
Temporary Solution:
An in-service was completed on 5/29/25 on Falls and the Raizer Lift for care team members. An in-service was completed on 6/24/25 on Medical Emergency Response, Fall Managment and Prevention, Fall and Injury Response, and First Aid for care team members.
Permanent Solution:
An in-service was completed on 5/29/25 on Falls and the Raizer Lift for care team members. An in-service was completed on 6/24/25 on Medical Emergency Response, Fall Managment and Prevention, Fall and Injury Response, and First Aid for care team members.
Wellness Director and Executive Director will review incident reports daily. If documentation incomplete immediate action will be taken. Annual training with care team on above and as needed in person or through our Relias training system.
Person Responsible:
Shannon Brown-Executive Director
Summary:
No deficiencies were found during the on-site investigation of complaint 00143444 conducted on September 17, 2025.