complaint·September 12, 2023

Record review at 3:00 p.m. today revealed R1 was taken to the hospital where it was discovered that R1 broke a bone in their elbow. R1’s care plan stated staff were to check on R1 every two hours. A supervision log revealed R1 was checked last at 9:00 a.m. on 09/09/2023. Therefore, the facility properly attended to and supervised R1. Based on interviews and record review, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff handled resident in a rough manner causing bruises” it was alleged Staff #2 (S2) caused bruising on the hand of Resident #2 (R2) after squeezing too hard. LPA observed R2’s hand today at 2:15 p.m. today and observed no bruising or discoloration. Interview with R2 today at 2:15 p.m. revealed R2 was not in pain and S2 did not squeeze too hard during the alleged incident. Interviews with other residents between 10:00 a.m. and 2:25 p.m. today revealed staff do not handle residents roughy. Interview with S2 at 1:25 p.m. and Staff #3 (S3) at 2:00 p.m. today revealed R2 often punched S2, S3, and other staff members. Based on interviews and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Residents sustained unexplained injuries due to neglect” it was alleged Resident #3 (R3) had unexplained bruising on their legs. Observations at 4:30 p.m. today revealed R3 had no bruising or discoloration on their legs. Interviews with residents between 10:00 a.m. and 2:25 p.m. today revealed no residents had unexplained injuries. Interview with S2 at 1:25 p.m. and S3 at 2:00 p.m. today revealed staff performed daily body checks for R3 and did not observe any bruising or discoloration. Record review at 3:00 p.m. today revealed R3 fell at the facility and was properly assisted by staff afterwards. Based on interviews, record review, and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are inappropriately medicating residents”, it was alleged residents were provided medication to make them sleepy. Resident interviews between 10:00 a.m. and 2:25 p.m. today revealed no residents took or were provided medication which was not prescribed. Staff interviews between 9:35 a.m. and 2:40 p.m. today revealed physician orders were followed when assisting residents with medication. Record review today at 3:00 p.m. confirmed staff followed physicians orders when assisting with medications. No additional medication was provided to make residents sleepy. During observations of the medication room at 2:40 p.m., LPA observed medication matched physician’s orders and medication lists. Based on interviews, record review, and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff is force feeding resident” it was alleged Resident #4 (R4) was fed too fast and choked. Attempted interview with R4 today at 11:25 a.m. did not reveal any information. Interviews with S2 at 1:25 p.m. and S3 at 2:00 p.m. today revealed staff are trained on proper feeding techniques. S2 recalled approximately 3 weeks ago, R4 choked during lunch. S2 assisted with removing the food and reassessed R4 for any further pain. LPA observed staff feeding residents during lunch today between 11:30 a.m and 12:15 p.m. and noticed proper feeding techniques applied. Based on interviews and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.