Complaint·December 31, 2024

The investigation revealed the following: Allegation #1-Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the resident (R1) had a fall at the facility two days prior before (R1) was taken to the hospital for head trauma and dizziness; and no one sought medical attention for the resident. On 12/19/24, from 12:00pm-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not seek medical attention for resident in a timely manner. All staff (S1-S4) interviewed stated that the facility had no knowledge of a fall and that they informed the family member on 12/14/24 when it was discovered that R1 had dried blood on the left side of R1s face and shaved hair in spots on the left side of R1s head as well. Staff stated that they checked R1s room for evidence of a fall and did not notice anything out of the ordinary. Staff also stated that they checked R1s room, floors, pillows, bathroom, furniture, and clothing for blood stains and could not find any. S2 stated that they observed the dried blood on R1 and asked R1 if R1 was in pain, R1 said no. S2 then asked who shaved your head like that, did you or anyone else do that, R1 said R1 was not sure. S2 then stated that they alerted management and management called the family member the same day that it was noticed on 12/14/24, and the family came and took R1 to urgent care. Staff also stated that they had no reports that R1 had fallen and when asked if R1 had fallen, R1 said no. Staff (S3) stated that S3 saw R1 on 12/13/24 and R1 looked fine and had no issues. But that on 12/14/24 they noticed a problem. S1 stated that the resident had shavers in R1s room, S1 stated that they packed them up and gave them to R1s family member. The Department reviewed the Unusual Incident/Injury Report (Dated: 12/19/24) that was sent to the department noting that R1 was found with dry blood and part of the top of R1s left head shaved in spots. The department also reviewed the After Visit Summary (Dated: 12/14/2024) that noted R1 had dry blood on left forehead and was unclear of etiology. The report also stated that R1 had no acute intracranial abnormalities. R1 was evaluated and returned to the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not seek medical attention for resident in a timely manner. The majority of the residents interviewed (9 of 10) stated that they have not had any problems with staff seeking medical attention when they need it. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not seek medical attention for resident in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . Complaint Investigation Report Continued on LIC9099-C Allegation #2- Staff did not keep resident's authorized person informed about incidents involving the resident. The details of the complaint alleged that the staff did not inform the resident’s authorized person about the incident that occurred at the facility. On 12/19/24, from 12:00pm-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not keep resident's authorized person informed about incidents involving the resident. All staff (S1-S4) interviewed stated that the family member was notified on 12/14/24 when they noticed that the resident had dried blood and hair that was shaved in spots on the left side of R1s head. Staff (S4) stated that the family member was notified that day and that S4 sent the family member a picture of R1 that showed the dry blood and shaved hair. S4 also stated the family responded by coming to the facility on that same day and as a precaution took R1 to urgent care. All staff (S1-S4) corroborated that the family member was made aware of the incident with R1. The department reviewed the Resident Incident Charting Notes (Dated: 12/14/2024) that showed the incident was logged and the family was notified. The department also received an incident report (Dated: 12/19/24) that was sent to the Department of Social Services, Community Care Licensing Division, detailing the incident. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not keep resident's authorized person informed about incidents involving the resident. The majority of the residents (9 of 10) interviewed stated that the staff does inform their authorized person when they have incidents at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not keep resident's authorized person informed about incidents involving the resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.