Complaint·May 7, 2024

The complaint was investigated further by the Department of Social Services Investigator Veronica Padilla. During the course of the investigation, Investigator Padilla interviewed the administrator, 12 Staff members, a personal caregiver, a family member, and 2 Residents. Medical records, Emergency Patient Care report, and Medical Examiner case report for Resident #1 (R-1) were gathered and reviewed. The investigation revealed the following: Allegation – Questionable death of resident. It has been alleged that Resident #1’s (R-1) death was caused by Staff #1 (S-1) who was neglectful towards the resident. On 10/3/23 around midnight, R-1 was found on the bathroom floor and sustained injuries. R-1 died 4 days later in the hospital. Based on interviews and record review by Investigator Padilla, it was determined that 2 Staff failed to provide supervision for R-1 during their shifts. S-1, who works the overnight shift, did not check on R-1 until staff heard moaning noises coming from the room. S-1 immediately called 911 when R-1 was found on the bathroom floor. Another staff admitted that during the last 4 hours of the shift on 10/2/23, staff did not check on R-1. The approximate day and time in which R-1 fell was unknown since neither staff checked on resident when they were supposed to. Although R-1 fell and sustained injuries, there is no evidence to show a causal link between the failure to conduct timely rounds and the resident’s death. In addition, the Department of Medical Examiner case report ruled the death as an accident. 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. An exit interview was conducted. A copy of this report along with the appeal rights were provided to the Administrator.