complaint·August 2, 2023

ED Willis indicated that S1, S2 and S3 have been placed on administrative leave pending an internal investigation. ED Willis indicated that a skin assessment was conducted the following day and noted that the only bruising R1 presented was on R1’s forearms due to R1 bumping into walls or doors. Lastly, ED Willis stated that a De-Escalation Techniques training, Mandatory Reporter training and Elder Abuse training was going to be conducted with all staff in the near future. LPA Ascencio obtained copies of written statement from S1, S2, and S3, the Skin Monitoring Review conducted on 07/21/2023, R1’s Charting Notes and R1’s LIC 602 Physician’s Report. According to R1’s LIC 602 Physician’s Report, R1 has a diagnosis of Alzheimer’s Disease/Dementia and 1 other diagnosis, no behavior conditions such as aggression or sundowning, and needs assistance with activities of daily living (ADL). A review of R1’s Charting Notes revealed R1 has had 2 fall, and 10 notes on aggression or agitation towards staff or other residents. Additionally, R1 is currently taking Quetiapine Furmate 25 mg at bedtime for agitation. On 07/28/2023, LPA Ascencio conducted an interview with R1’s Family Member beginning at 1:45 p.m. Interview with R1’s Family Member revealed that the staff could not have treated R1 in a rough manner. Family member added that since moving into The Preserve in May 2023, they have had a wonderful time, with the best care staff experience. R1’s Family member stated they do not suspect that R1 was abused or mistreated by S1, S2 or any staff. Lastly, R1’s Family Member added that due to R1’s diagnosis of dementia, R1 has been presenting with more aggressive and agitative behaviors that are being monitored and controlled by medication. On 08/02/2023, starting at 2:10 p.m. interview with S1 was conducted revealing that R1 was in another resident’s room. When S1 and S2 attempted to redirect R1 out of the room, R1 began to get aggressive with the staff. S1 and S2 started to walk with R1 out of the room when suddenly R1 became “dead weight” and attempted to drop to the ground. S1 stated that both S1 and S2 were grabbing R1 underneath their arm preventing a fall, while R1 was trying to fall to the floor. S1 continued, at this moment, S3 came and observed the situation stated that we are handling R1 in a rough manner. That same day, interview with S2, starting at 2:20 p.m. confirmed what S1 stated and added that R1 did not fall to the ground but instead, was being held up by S1 and S2. Also, that same day, interview with S3, starting at 4:05 p.m. confirmed what S1 and S2 stated but added that S3 witnessed S1 and S2 swinging R1 around to get R1 out of another resident’s room, which was empty. S3 added that R1 was not agitated, both staff members could not provide a reason as to why R1 was removed from the room. Lastly S3 stated R1 did not fall to the ground but was being handled inappropriately. Continued on LIC 9099 - C Although a skin assessment was conducted on R1 the following day the alleged incident occurred, according to ED Willis, the skin assessment report indicated that the current bruises R1 had, was from R1 bumping into things in the facility. Additionally, ED Willis stated there was no indication that R1 was grabbed at the wrist or in any part of the arm as R1’s arm had no marks or bruising that suggest R1 was handled in a rough manner. Additionally, interviews with S1 and S2 indicated that they attempted to redirect R1 out of the room causing R1 to get upset and agitated, thus attempted to fall to the ground. S1 and S2 held onto R1 to prevent a fall and R1 causing self-harm by falling. At this moment S3 walked in and observed the situation accusing the staff members of abusing R1 by forcing resident out of the room. Interview with R1’s Family Member stated they do not suspect R1 was abused or mistreated and is enjoying their time and care the staff are providing R1. Thus, based on the evidence gathered there is insufficient evidence to prove that staff handled resident in a rough manner and resident sustained a fall while in care. Both allegations are deemed unsubstantiated at this time. LPA Ascencio and ED Willis confirmed that further training is recommended on elder abuse and mandated reporting, in addition on interventions on dementia behaviors and documentation. Exit interview conducted and a copy of the report was issued.