Incident investigation·March 22, 2023

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address a potential violation reported during the investigation of complaint #18-AS-20230314155846. The LPA met with Luz Rodriguez, Care Consultant, and informed her of the purpose of the visit. The LPA received a verbal report on March 22, 2023, of a resident (R1) sustaining injuries as a result of being pushed by a staff member (S1). The LPA conducted staff/resident interviews, reviewed records, and took copies of relevant documentation. According to an Unusual Incident Report (UIR) R1, on March 14, 2023, sustained a fall, was observed to be bleeding, and emergency services was called. R1 was interviewed; R1 reported they were pushed by an unknown staff member, injured their head, and was later transported to the hospital. According to Rodriguez, video surveillance captured the alleged incident. The LPA reviewed the recording and observed a resident, appearing to be R1, having an argument with an unidentifiable individual. The recording shows S1 stumbling and eventually falling on their back. The recording did not capture any other individual(s), though a second voice can be heard. Staff reported the second voice heard in the recording is of S1. Staff also reported S1 would have been the only staff on shift at the time of the incident. If additional information is received indicating a violation occurred, then a follow up visit will be conducted. This report was reviewed with Rodriguez and a copy was provided.