complaint·February 4, 2025

Allegation: Resident sustained an unexplained injury due to staff neglect. It is alleged that a resident sustained an unexplained injury due to staff neglect. Regarding this allegation it is reported that Resident #1 (R1) sustained an injury of unknown origin on 1/29/2025. It was stated that when Staff #1 (S1) left R1 for the night on 1/28/25 when S1’s shift ended, R1 had no visible injuries, however when S1 returned the next day, R1 had an injury to R1’s right arm. This injury of unknown origin caused R1 to be taken to the emergency room for further evaluation. LPA Casillas interviewed Administrator and it was revealed that Administrator checked on R1 the morning of 1/29/25 at 09:30am and performed grooming needs for R1, this included a body check and there were no visible injuries. Later at approximately 10:40 am Administrator states that S2 made them aware that there was bruising and swelling to R1’s right arm. This was cause for alarm and Administrator called 911 that resulted in R1 visiting the emergency room. Administrator states that R1 did not cry out or alert any of the staff that R1 was hurt or in distress and that they are not sure as to how R1’s arm was injured as R1 is nonverbal and could not communicate with staff. Furthermore, Administrator stated that as soon as they were made aware of the bruising, they took immediate action and called 911. LPA Casillas was able to conduct a phone interview with S1 and S1 revealed that when their shift was over on 1/28/25, R1 seemed in good condition and that they are not sure how R1 was injured as they did not witness any falls or injuries, nor have other staff members mentioned any incidents. LPA Casillas’ interview with Staff #2 (S2) revealed that they also do not know how R1 was injured as they have not witnessed any falls or injuries and S2 is not sure as to a possible cause of injury. LPA Casillas attempted to interview R1 however, as previously stated, R1 is non-verbal and LPA was not able to obtain information. LPA Casillas along with S2's assistance was able to observe R1’s arms from fingertips to shoulders and there were no other visible injuries aside from R1's right arm in a cast, there was no visible bruising or swelling. Interviews with Resident #2 and #3 (R2, R3) also revealed that they have not witnessed any injuries, falls or any staff hurting any residents. During LPAs record review of R1’s medical records there was no indication on how this injury was obtained, furthermore there is no record that this was an injury due to staff neglect, records only indicate that there was a fracture due to an injury of unknown origin and that 911 services were called to assist R1. Therefore, based on observations, interviews and record reviews, this allegation of " Resident sustained an unexplained injury due to staff neglect." is deemed unsubstantiated. No citation issued. Exit interview conducted. Copy of report given to Administrator.