complaint·August 27, 2024

The complaint alleges that R1 sustained unexplained bruising while at the facility. Record review revealed that R1 had a diagnosis of dementia and resided in the facility's memory care unit. While residing at the facility, staff indicated that R1's dementia progressed and that R1's behaviors escalated. R1 became difficult to care for, as R1 became more aggressive with staff and refused care. Nurse's notes reviewed indicated R1 had an unwitnessed fall on 01/12/2024, which resulted in staff calling 9-1-1 and obtaining outside medical treatment for R1. Staff interviewed indicated that R1 was aggressive when EMTs arrived to take R1 to the hospital. R1 was large in stature and that 4 EMTs were observed holding R1 to the gurney while taking R1 out of the facility. Resident returned from the hospital the same day with no known injuries noted. On 01/16/2024 and 01/17/2024, bruising was noted on R1's forehead, nose and under eye. Staff notes indicate family was informed of the noted bruising. On 01/19/2024, additional bruising was noted on R1's arms, hip and back and R1 was taken to urgent care for observation of the bruising. Text messages between facility and PCP were provided to LPA indicating the bruising and request for outside medical treatment. Staff interviewed indicated that at the time of the allegation, R1 had increasing paranoia and possible hallucinations. R1 reported not trusting care staff and refused full body showering. Therefore, staff was unable to clearly observe R1 for physical changes or bruising timely, as R1 refused observation. As R1 refused observation and a full body check for injuries, it is difficult to ascertain when the bruising occurred and whether the resident was present at the facility during the time of the alleged bruising. Additionally, as the bruising was noted but of unknown origin, there is no way of knowing how the bruising occurred and whether it was a result of a lack of care and supervision at the facility. Both residents and staff interviewed indicated they have never heard of or observed any staff being rough with the residents and residents feel safe at the facility. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "resident sustained unexplained bruising" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.