complaint·January 16, 2025

Department Incident Report related to the complaint allegation, reviewed medical records for Resident #1 (R1), documents related to R1 and Resident #2 (R2), and interviewed facility staff, residents, and other relevant parties on the following dates: 10/22/2024, 11/13/2024, 11/14/2024, 11/20/2024, and 12/07/2024. The following was then determined: It was alleged that facility staff did not provide an appropriate level of supervision, resulting in R2 attacking R1 and R1 sustaining a head injury. Review of R2’s facility records revealed that R2 had moved into the facility on 06/21/2024. Interviews with R2’s physician, Power of Attorney (POA) designee, and trustee all revealed that R2 did have a diagnosis of dementia, but R2 had no history of aggressive or assaultive behavior at the time R2 moved into the facility. Hospital records dated prior to facility admit did indicate R2 is “supposed to have 24/7 caregivers” but did not indicate the reason 24/7 care was requested. Trustee indicated they had informed the hospital staff of this request due to R2’s care needs becoming greater and resulting weight loss, but reiterated that R2 had displayed no prior aggressive behaviors. Hospital records did not indicate any aggressive behaviors were observed. When R2 moved into the facility, facility staff conducted 72-hour behavior mapping, as outlined in the facility’s protocol for all new residents. R2 did not display any aggressive behavior towards other residents during the 72-hour period. From the time R2 moved into the facility until the date of the incident, per their responsible party’s request, R2 had a private companion with them during normal business hours Monday through Friday. Incident reports reviewed revealed R2 had been involved in an incident with another resident on 06/30/2024, where R2 had pushed another resident. However, the incident did not result in injury to either resident and facility staff had reported the incident to R2’s physician, who adjusted R2’s medication. No additional incidents or aggressive acts were observed involving R2 and any other residents until 08/23/2024. R2’s private companion had been working with them during the daytime, but had gone home for the day prior to the incident. Incident report reviewed and staff interviews revealed that facility staff had assisted R2 with getting ready for bed prior to 09:00PM on 08/23/2024. R2 had appeared somewhat frustrated when care staff were providing R2 with assistance, but staff reported this behavior is typical of residents with dementia, including R2. Care staff had left R2 in their room in bed, but that R2 did not require 1:1 supervision and residents are free to leave their rooms whenever they choose. Around 09:00PM, facility staff heard a noise in the hallway near the patio and staff reported to the area to see what had occurred. When staff arrived, R2 was standing up and R1 was laying on the ground on their back. Facility staff assessed both residents and called 9-1-1 due to R1’s observed injuries. As both residents have a diagnosis of dementia, it wasn’t until Report Continued on LIC 9099-C video recordings were reviewed that staff found out what had occurred between the two residents. Video recording shows that R1 was in the hallway facing R2 when R2 approached R1. R2 grabbed either one or both of R1’s arms, appears to shake R1, and R1 takes several steps back before falling backward. As R1 falls backward, R2 falls forward onto R1’s right side. R2 gets up off the ground before staff report to the hallway. R1 was taken to the hospital where x-rays revealed a “subdural hematoma along the left cerebral hemisphere and left falx cerebri with tiny parenchymal hemorrhagic foci indicating contusion seen in the left nondisplaced subtle fracture of the right occipital bone.” All staff interviewed acknowledged that at times R2 had been resistant to care provided and R2 would occasionally hit at the care staff while they were providing care. However, staff interviewed indicated they had not witnessed any prior incidents where R2 had acted aggressively toward another resident. All third-party interviews conducted revealed that R2 had no history of aggressive behaviors and that when any new behaviors were identified by facility staff, that the facility acted swiftly to communicate with R2’s medical provider and responsible parties. Additionally, prior to the incident occurring, there was no documentation or indication R2 required 1:1 staff supervision. Following the incident, facility management required R2 to have a 1:1 companion at all times while in the facility as a preventative safety measure. After reviewing video footage of the incident, facility management chose to initiate an eviction for R2. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.