complaint·May 30, 2024

R2 walked to the facility’s front desk and informed staff of their injury and requested emergency services. Interviews revealed when staff entered R1’s room after the physical altercation, they noticed R1’s dresser drawer was open. They observed blood on the edge of the drawer and directly below the dresser drawer was a pool of blood on the carpet. It was reported when staff entered R1’s room, R1 had two canes, one on the wall and one on the floor with no traces of blood on either canes. Interview with R1 revealed R2 entered R1’s room and started hitting R1. R1 reported they are not aware of a prior verbal or physical dispute with R2 that initiated the physical altercation. R1 and R2 have two separate rooms but share one bathroom. Administrator Fruit reported arrangements were made to have R2 move into a different room when they returned from urgent care but R2 refused to move rooms. Interviews conducted with R1 and R2 revealed neither of the residents wanted to move rooms after the physical altercation. R2 reported no verbal disputes or physical altercations with R1 after May 17, 2024. Interviews and records review revealed R1 and R2 did not have any prior incidents involving physical aggression or verbal disputes while residing in the facility. Records review of Physician’s Report for R1 revealed R1 is able to perform their activities of daily living (ADL) with no supervision or assistance from staff which includes bathing self, grooming self, feeding self, and care for own toileting needs and R1 does not have a history of aggressive behavior. Physician’s Report for R2 revealed R2 is able to perform their activities of daily living (ADL) with no supervision or assistance from staff which includes bathing self, grooming self, feeding self, and care for own toileting needs. It is recorded R2 has aggressive behaviors “at times”. Interview with staff one (S1) reported after R1 and R2’s physical altercation, staff were instructed to conduct daily observations and monitoring during each shift and document R1 and R2’s behaviors. Staff interviews corroborated staff were informed and implemented a plan to increase monitoring of R1 and R2’s interactions. Staff also reported the plan included redirection of interactions between R1 and R2 when necessary. Records review revealed on May 20, 2024, staff began documenting R1 and R2’s behaviors daily based on a number system indicating aggressive behaviors observed. Zero (0) indicated no aggressive behavior observed, one (1) indicated yelling observed, two (2) indicated cursing was observed, and three (3) striking out or being physically aggressive was observed. R1 and R2 had zeros documented daily for each shift from May 20, 2024 to May 30, 2024. Based on interviews and records review, staff did not have any indication that the interaction between the two residents was escalating prior to R2 entering R1’s room to prevent the physical assault. Therefore based on interviews and records review, the allegation “Staff did not prevent a resident from physically assaulting another resident in care” has been deemed unsubstantiated at this time. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided. An exit interview was conducted with Administrator Fruit and a copy of this report, LIC 811, and LIC 9099C was provided.