Complaint·September 12, 2024

due to an end stage illness. All Hospice agencies contacted and conservator where unaware of any staff neglect. Based upon this information gathered LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED Regarding Allegation : Staff did not prevent a resident from causing self harm It was alleged that facility staff did not prevent a resident from causing self harm by cutting her wrist. During this visit LPA reviewed incident report of this incident dated 5/30/2024. LPA interviewed Staff #1 and Staff #2 which are both Med room staff who observed R#7 on day of incident. Incident report and staff interviews were consistent with incident: R#7 brought scissors to the Medroom and asked the staff to keep her scissors for her. Staff #1 asked R#7 why did she want them to hold the scissors for her and R#7 stated It would be safer for her. Staff took the scissors. Staff insist that R#7 did not seem distressed and acted normal. Later R#7 sustained a self cut to her wrist. LPA Day interviewed Administrator Suzette Johnson who explained the facility procedures of when a resident presumes to be distress or unusual behavior, that resident is put on a hourly watch. After R#7 brought the scissors to the Medroom S#1 alerted Administrator and was put on an alert. However R#7 cut herself within minutes of leaving the Medroom. LPA reviewed Physician report and Needs and Service Plan of R#7 which did not indicate any history of suicidal tendencies nor a history of cutting herself. During this visit LPA was unable to interview R#7 due to she has moved and whereabouts are unknown. Based on the information gathered and the interviews conducted LPA Day finds that the Staff had no knowledge of R#7 intent to harm herself , therefore could not prevent it. There is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED An Exit interview was conducted with Suzette Johnson Administrator and Sidonia Cordis, Resident Care Director and a copy of this report was provided