complaint·November 13, 2023

The investigation revealed the following: Allegation #1 - Resident sustained bruises while in care. This allegation was investigated by Investigator Juan Lozano from the Department Investigations Branch. Interviews were held with the facility staff, a family member, and a personal caregiver. Medical records were also obtained and reviewed to determine this finding. The medical records did not indicate Resident #1 (R-1) had visible bruising by staff during a hospital visit. R-1’s caregiver also had not observed any visible injuries when visited R-1 at the facility. LPA interviewed additional staff for this allegation. They stated R-1 had bruises upon admission on 12/1/22 and did not observe any new ones during the short stay at the facility. In addition, LPA interviewed a hospice liaison who confirmed R-1 had bruises prior to being admitted to the facility and has skin issues which causes resident to bruise easily. Allegation #2 - Staff did not assist resident with obtaining medical care . It was alleged R-1 had a fall and did not seek medical attention. Documentation showed that R-1 had a fall on 12/17/22 and complained of a headache. Staff interviewed stated that due to the fall and the headache, they immediately contacted 911. They came and transferred R-1 to the hospital. The facility notes indicated the fall, 911 was called, and reported to the hospice nurse and R-1’s wife. According to the administrator and staff, when a resident sustains a fall, they would check the resident and contact the paramedics as a safety precaution. All 4 residents interviewed stated the staff would seek medical attention for anyone that needs it. Allegation #3 - Staff did not assist resident with ambulating which resulted in resident developing rashes . It was alleged that R-1 developed rashes due to sitting in a chair for prolonged periods of time and not ambulating from chair. Per administrator and staff, they encourage residents to move around throughout the day to prevent rashes. Those in wheelchairs are transferred to and from their beds and/or repositioned in their seats. Residents are brought out to common areas and encouraged to participate in activities. Staff interviewed did not recall seeing any rashes on R-1 and stated they did not allow R-1 or any residents in wheelchairs to sit for long periods of time. Allegation #4 - Staff did not communicate with resident's responsible party. It was alleged that Resident #1 (R-1) fell and did not inform the responsible party of the fall. Staff who witnessed the fall stated they contacted R-1’s responsible party after calling 911. R-1’s responsible party was upset at staff for calling the paramedics and hung up on staff. Administrator and staff stated they had always been in communication with R-1’s family member during visitations and would return phone calls. LPA obtained a copy of the staff notes which documented the communications with resident’s wife. They stated they communicate with other residents’ families as well and provide updates of residents’ conditions when necessary. Allegations #5 - Staff did not release resident's personal belongings to responsible party and #6 - Staff did not safeguard resident's personal belongings. Per the administrator and staff, when a resident moves in, they fill out the Resident Personal Property and Valuables form to indicate any items brought into the facility. As for R-1, they stated R-1’s inventory form only listed articles of clothing. When R-1 moved out, the clothes were returned and R-1’s responsible party signed. LPA reviewed and obtained a copy of the signed list of inventories returned. Staff interviewed stated that they would safeguard resident’s personal belongings by washing their clothes separately so they do not mix them up with another resident's. They keep an eye on where residents go and make sure they do not take things that do not belong to them. They stated no residents had reported anything missing. Residents interviewed stated did not have any thing missing as well. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Daisy Fitter. A copy of this report along with the appeal rights were provided.