complaint·August 24, 2023

Regarding Allegation #1 : Resident sustained injury while in care. The complaint alleges that R1 sustained injury when R1 fell out of elevator onto the facility 2 nd floor. On 05/20/2022 LPA Calderon interviewed A1 who expressed that R1 was seen leaving by facility staff in R1 wheelchair around 6pm as R1 was doing some shopping. A1 expressed that R1 called a taxicab and then returned to the facility around 10 pm with shopping bags on the back seat chair of R1 wheelchair and a twelve pack of soda on R1 lap. A1 expressed that S2 noticed resident was having issues moving in the wheelchair and helped resident to resident room on the second floor. A1 expressed that S2 asked R1 if R1 needed help and R1 agreed. On 02/17/2023 LPA Calderon interviewed S2 who expressed that S2 noticed R1 struggling with R1 grocery bags and the 12 pack of soda while moving R1 wheelchair. S2 expressed that S2 helped R1 to the elevator with all his bags of food. S2 helped R1 into the elevator and pushed the second-floor button. S2 expressed that S2 got out of the elevator 2 as R1 started to push R1 wheelchair forward. S2 expressed that R1 front wheel of R1 wheelchair got stuck between the elevator and the second floor and resident fell forward contacting the 2 nd floor landing. S2 expressed R1 had minor scrape to left eye area but there was no major blood found on the ground and R1 had no other injuries. S2 expressed that S2 helped R1 get up from the 2 nd floor landing after the fall when another resident opened their front door. On 02/17/2023 LPA Calderon reviewed physician report (02/08/2022) which suggest that R1 is capable to taking care of R1 needs. LPA Calderon reviewed hospital records (05/07/2022) and reported minor scrape to resident left eye area. Per hospital records R1 was discharged to the facility on 05/07/2022 which was the same night as the incident. Regarding Allegation #2 : The elevator kept closing on the resident. This complaint alleges that the elevator kept closing on residents’ legs and body. On 05/20/2022 LPA Calderon interviewed A1 who expresses that R1 fell out of R1 wheelchair when R1 wheelchair got stuck between the elevator and the 2 nd floor landing. A1 expressed that R1 fell forward, and the elevator door kept opening and closing on R1 as the door sensed an object in the door opening. On 02/17/2023 LPA Calderon interviewed S2 who expressed that R1 front wheel of R1 wheelchair got stuck between the elevator and the second-floor landing. S2 expressed that the elevator door opened and never contacted R1 legs. S2 expressed that S2 pushed the stop button and the elevator doors stayed opened. On 02/17/2023 LPA Calderon interviewed S3-S8 who expressed that S3-S8 have never been injured by the elevator door. On 02/17/2023 LPA Calderon interviewed R1-R13 for complaint. R1 was not able to give a statement due to health issues. 12 out of 12 residents expressed that no resident has been injured by the elevator door. On 02/17/2023 LPA Calderon reviewed written report from front desk employee dated 05/07/2022. Front desk staff written report supports S2 verbal facts of loss. On 02/17/2023 LPA Calderon reviewed Tre Elevator Corp maintenance records (5) dated 01/21/2022 to 05/05/2022 there was no mechanical issues noted. On 02/17/2023 LPA Calderon and A1 toured the facility and used the 3 facility elevators. The elevator door has sensors which open if there is an object that contacts the door. LPA Calderon placed his right hand in elevator door #2 and the door stopped opening when door sensed an object in the landing area. LPA Calderon was able to stop the elevator door from closing by pressing a red button. Regarding Allegation #3 : Staff was unable to call 911. This complaint alleges that staff could not call 911 for an emergency. On 05/20/2022 LPA Calderon interviewed A1 who expressed that all staff and resident have cell phone coverage and any facility hard line which are located on every floor that staff and residents can call 911 for an emergency. On 02/17/2023 LPA Calderon interviewed S2 who expressed that R1 had fallen out of R1 wheelchair when R1 wheelchair got stuck. S2 was helping R1 when another resident opened their front door and called 911. S2 expressed that S2 did not have the chance to call 911 prior to the other resident who opened their front door and called 911 for R1. On 02/17/2023 LPA Calderon interviewed S3-S8 all expressed no issues in calling 911 when staff needs to. On 02/17/2023 LPA Calderon interviewed R2-R13 for complaint. 12 out of 12 residents expressed no issues in calling 911 from the facility if residents or staff need to call 911. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “resident sustained injury while in care” “the elevator kept closing on the resident” “staff was unable to call 911” is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator Peggy Clark (A1).