complaint·November 10, 2021

Interviews with staff revealed after dinner, staff responded to a scream by R1 and found R1 in the courtyard on the ground alleging R2 pushed R1. R1 was assessed and the residents were separated. Staff interviews revealed there was no history of R1 or R2 being physically aggressive with each other or with other residents. Record review also did not find any evidence to support this. Staff stated since the incident, they are now watching R2 more carefully. Based on the information obtained, although an altercation may have occurred between R1 and R2, there is insufficient evidence to support the incident was a result of lack of supervision. Therefore, the allegation of 'Resident hit another resident in care' is deemed unsubstantiated at this time. The allegation of ' Resident did not receive medical treatment for their injury' alleges R1 did not receive medical treatment for their injury due to R1 not having a doctor. Interviews with staff revealed R1 was offered emergency services when the incident occurred but denied these services and denied having any injury. On the day of the incident, the facility nurse observe R1 for injury. Record review revealed on 10/21/2021, R1's physician on file was faxed regarding the incident but the physician returned the fax on 10/25/2021 indicating R1 was no longer their patient. Staff interviews revealed they were not aware of R1 no longer having a physician prior to this. Interviews revealed in the days following the incident, R1 complained of intermittent pain to their shoulder and R1's family was contacted to obtain a new physician for R1. Record review revealed R1 was seen by a physician on 11/3/2021, had an x-ray on 11/8/2021, and seen at an urgent care on 11/9/2021. Based on the information obtained, there is insufficient evidence to support the allegation of 'Resident did not receive medical treatment for their injury' occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview and report reviewed with Administrator Joey Alvarado. A copy of the report and appeal rights was emailed.